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BY THE SAME AUTHOR. 



THE CELL DOCTRLNE : Lts History and Present 
State ^ together with a Copious Bibliography of the 
Subject. With a Colored Plate and other Lllustrations 
on Wood. 

PRICE, $2.00. 



AN LNTRODUCTLON TO THE STUDY OF 
PR A CTLCAL HISTOL OGY. For Beginners in 
Mic7^oscopy. 

Price, $1.00, Interleaved, $1.^0. 



A GUIDE 



PRACTICAL EXAMINATION 



URINE. 



FOR THE USE OF PHYSICIANS AND STUDENTS. 



BY 

JAMES ^YSON, M.D., 

Hospital Lecturer 07i Pathological AnatoDiy in the University of Fennsylvania ; 

One of the Physicians and Pathologist to the Philadelphia Hospital ; 

Professor of Physiology and Histology in the Pennsylvania 

College of Dental Snrgery ; Fellow of tJie 

College of Physicians : Etc., Etc. 



WITH A PLATE AND NUMEROUS ILLUSTRATIONS. 



P II 1 L A D E L r II I A : 
LINDSAY & IVLAKISTOX. 

18 7 5. 



66 




^^l 






■^^.^i- 



Entered according to Act of Congress, in the year 1874, 

By LINDSAY & BLAKISTON, 

In the Office of the Librarian of Congress, at Washington, D. C 



SHERMAN & CO., PRINTERS, 
PHILADELPHIA. 



PREFACE. 



Doubtless it will be thought by some that there is 
no present necessity for an additional volume on the 
subject which the title of this pretends to cover. Such 
was, indeed, the writer's own impression, when urged, a 
few months ago, to prepare it. Some reflection, hoAvever, 
convinced him that, while there were quite a number of 
comprehensive works of great value, and a smaller num- 
ber of manuals or guides for the examination of urine, 
the latter seemed altogether too limited, while the former 
are too bulky to be convenient for daily use. It was 
further thought that an experience of several years in 
almost daily microscopical and chemical examinations of 
urine for others and himself, as well as in teaching the 
subject in the Univei'sity of Pennsylvania, had given the 
author such familiarity with the practical wants of the 
physician, as would appear to justify his attempting to 
supply them in a convenient shape. 

Pains have been taken to secure a completeness of 
illustration not usual in the smaller works, while the 
methods for the most exact quantitative, as well a> a[)- 



VI PREFACE. 

proximate analysis, have been included, without too 
much increasing the size of the volume. 

The modes of approximate estimation so commonly- 
used in the German laboratories, it is believed, are here 
published for the first time in English. For the details 
of these the writer is indebted to the admirable practical 
treatise of Hoffinann and Ultzmann, so often referred 
to in the text. To Messrs. Lindsay & Blakiston ac- 
knowledgment is due for the privilege of using electro- 
types of certain cuts in the American edition of Dr. 
George Harley's work ^^ On the Urine and its Derange- 
ments," and to Dr. C. B. Nancrede for assistance in 
drawing and coloring. 

332 So. Fifteenth Street, 
Nov. 1st, 1874. 



LIST OF ILLUSTRATIONS. 



PAGE 

Plate — Pigment flakes, opp 148 

FIG. 

1. Measuring-glasses, ....... 18 

2. Apparatus to determine specific gravity of urine 

(Harley), 27 

3. Heller's urinometer and stand, with cylindrical glass, 28 

4. 5. Test-tubes, with base, ...... 37 

6. Appliance for fermentation test for sugar (Harley), . 51 

7. Pavy's apparatus for the volumetric process for sugar, 55 

8. Crystals of nitrate of urea (Beale), .... 77 

9. Apparatus for the volumetric process for urea (Harley), 83 

10. Prismatic crystals of urate of soda, spherules of urate 

of ammonia, and amorphous urates with octahedral 

crystals of the oxalate of lime (Kanke), . . . 110 

11. Spiculated spherules of urate of ammonia, with crys- 

tals of the ammonio-magnesian phosphate and oxa- 
late of lime (Kanke), Ill 

12. More usual forms of uric acid crystals (Harley), . 114 

13. More unusual forms of uric acid crystals (Harle}^), . 115 

14. Prismatic crystals of urate of soda, spherules of urate 

of ammonia, and amorphous urates with octahedral 

crystals of the oxalate of lime (Ranke), . . . 120 

15. Octahedraand dumb-bells of oxalate of lime ( Harley "), 1-2 
10. Triangular prisms and modifications, of th(^ triple phos- 
phate (Harley), 127 

17. Stellar crystals of the triple phosphate (IIarley\ . 12S 

18. Crystals of phosphate of lime (llassall), ^ . . \oO 



Vlll 



LIST OF ILLUSTRATIONS. 



FIG. 

19. Leucin and tyrosin, ..... 

20. Cystin, 

21. Mucus- and pus-corpuscles, . . 

22. Different forms of epithelium found in the urine 

23. Blood-corpuscles, 

24. Epithelial casts and compound granule-cells, 
- 25. Blood-casts and granular casts, . 

26. Hyaline casts ; one protruding from a uriniferous tu 

bule (Rindfleisch), 

27. Waxy casts (Harley), 

28. Oil-casts and fatty epithelium, . 

29. Spermatozoids, . . . 

30. Yeast fungus (Harley), .... 



PAGE 

132 
134 
138 
144 
147 
150 
150 

151 
152 
153 

158 
IGO 



PRACTICAL EXAMINATION OF THE URINE. 



SECRETION OF URINE. 

The theory which explains the secretion of urine most 
consistently with the facts, is one which, while it makes 
it mainly physical, admits something also of the nature 
of elaboration in the acts of the kidney. Nothing can 
be more beautiful at first thought than the theory of 
Ludwig, according to whom the process is a purely phys- 
ical one — partly a transudation and partly a diffusion 
or osmosis. He correctly states that in the capillaries 
of the malpighian bodies, there is a greatly increased 
blood pressure caused by the resistance to the exit of the 
blood through the efferent vessel. As the result of this, 
a transudation of the watery constituents of the blood, 
with some dissolved salts, takes place into the malpig- 
hian capsule. Thus the blood is greatly thickened when 
it reaches the second capillary system surroundinu' the 
convoluted tubules which contain the thin a(|ueous trans- 
udation from the malpighian bodies. Here wo have 
then, the essential elements of a coni})lete (\<nionieter, — 



14 PEACTICAL EXAMIXATIOX OF THE URINE. 

an animal membrane in the thin ^vall of the capillary 
and the delicate basement-membrane of the tubule, 
with a dense fluid (the blood) on one side, and a thin 
saline solution on the other. An interchange now takes 
place, as the result of which a current sets in, of the 
water from the tubules to the blood, and of the prod- 
ucts of regressive metamorphosis, urea, etc., and salts to 
the tubules, concentrating the fluid in the latter, making 
it in other words urine ; while the albuminous constituents 
of the blood are retained there, because of their well- 
known resistance to osmosis. 

Two important facts, however, remain unaccounted 
for by this theory, beautifully simple as it is. These are, 
1st, that if the tubules are striiDped of their epithelium 
as they are in disease, urea and other products of regres- 
sive metamorphosis are no longer so freely removed; and 
2d, that we can hardly account in this manner for the pro- 
duction of an acid fluid from an alkaline one, as is the 
case. We must therefore admit some elaborating action 
on the part of the epithelium through which these results 
are obtained. Doubtless, however, the larger proportion 
of the act is a physical one — a process of transudation or 
filtration and of diffusion or osmosis."^ 



^ Since the above was written I have met {Medical News and 
Library for October, from the London Lancet of July Ist, 1874) 
the account of some experiments by Dr. Ralfe, in the laboratory 
of Charing Cross Hospital, London, which afford some expla- 



APPARATUS REQUIRED. 15 

REAGENTS AND APPARATUS REQUIRED FOR QUALITA- 
TIVE AND APPROXIMATE ANALYSIS.* 

It is not a matter of very great importance in what 
form of bottle reagents are kept. They should hold 
enough — four ounces is a convenient quantity — and be 
provided with ground-glass stoppers for the acids, but the 
alkalies are better kept in bottles with rubber stoppers. 
Those required are as follows : 

1. Pure colorless nitric acid (HNO3). 

2. Nitroso-nitric acid, the brown faming nitrous acid of com- 

merce, really nitric acid containing nitrogen tetroxide 
(HN03+N,0, or NO,). 

3. Pure hydrochloric acid (HCl). 

4. Pure colorless sulphuric acid (H2S0^). 



nation of this interesting phenomenon. He introduced an alka- 
line solution of sodium bicarbonate and neutral sodium phos- 
phate in a small U-shaped tube, fitted with a diaphragm at the 
bend, and passed a weak electric current through the solution. 
In a short time the fluid in the limb connected with the positive 
pole became acid from the formation of acid sodium phosphate, 
the substance which is the chief agent in producing the acid 
reaction of the urine, while the fluid in the limb connected 
with the negative pole increased in alkalinity. The changes 
are represented by the following formula : 

Sodium Neutral Sodiiini 

Bicaihoiiatv*. Phosphate. 

NalIC03 + Na,llPO, = 

'^' All reagents and aj^paratus suitable for urinary analysis, 
may be obtained of Bullock cV: Crenshaw, r)*J8 Arch Slr»>et, 
Philadelphia. 



Sod i inn 
Carbonate. 


Arid SiHUuiu 
rhosphato. 


Na.,CO, - 


{- ^^ilI.,PO, 



16 PRACTICAL EXAMINATIOX OF THE URINE. 

5. Pure acetic acid (CjH^Og). 

6. Liquor potassoe, U. S. P. The sp. gr. is 1065, and it con- 

tains 5j\ per cent, of potassium hydroxide (HKO). 

7. Solution of caustic potash, 1 part to 2 of distilled water, sp. 

gr. 1330 +, to be spoken of in the text as the " stronger 
solution of potash." 

8. Solution of barium- chloride, 4 parts crystallized barium 

chloride, 16 of distilled water, and 1 of hydrochloric acid. 

9. Liquor ammoniae, U. S. P. 

10. The magnesian fluid, containing of magnesium sulphate and 

pure ammonium chloride, each 1 part, distilled water 8 
parts, and pure liquor ammonite 1 part. 

11. Solution of copper sulphate, say 1 part to 4 of distilled 

water. 

12. Pavy 's or Fehling's copper solutions, made as directed under 

volumetric analysis for sugar. 

13. Solution of silver nitrate, 1 part to 8 of distilled water. 

14. Solution of lead acetate (sugar of lead), 1 part to 4 distilled 

water. 

15. Solution of basic lead acetate, 1 part to 4 distilled water. 

16. Distilled water, a litre or a quart. 

17. Alcohol, 95 per cent, a half litre or a pint, and others as re- 

quired. 

Ajyparatus. 
A note and drawing book. 
1 dozen test-tubes, assorted sizes, some narrow, with test-tube 

rack and drainer. (Some test-tubes, with bases, so that 

they may stand on a shelf or mantel, are convenient and 

desirable; see Fig. 4.) 
4 conical glasses. (Observe that they terminate in a point, and 

that there is not a convexity at the bottom.) 



APPAKATUS PvEQUIKED. 17 

Red and blue litmus-paper ; filtering-paper. 
Urinometer and urinometer glass. 
4 ground-glass covers, assorted sizes. 
Spirit-lamp. 

3 porcelain capsules. 

4 beaker glasses, small and medium sizes. 
^- dozen watch-glasses. 

8 glass funnels. 

Glass stirring-rods and dropping-tubes. 

1 large receiving-glass to measure twenty-four hours' urine, with 
capacity of 2000 cubic centimetres or more. 

1 graduated measuring-glass holding 500 c.c. 

1 wash-bottle with distilled water. 

1 retort stand ; water bath. 

1 or 2 sheet-iron tripods with wire gauze to cover. 

1 100-minim pipette; 1 volume pipette for 5 c.c, another for 
10 c.c. 

Platinum spoon. 

Blowpipe. 

Swabs for cleaning test-tubes, etc. 

A microscope with two object-glasses, a i or I inch, and a 1 
inch or -^^ inch ; stage micrometer ; camera lucida for 
drawing ; glass slides, thin covers, shallow cells ; test-bot- 
tles with capillary stoppers ; plain glass pipettes. 

For volumetric analysis are required in addition, 
A full set of volume pipettes, 5, 10, 15, 20, oO, 50 c.c. 

1 graduated dropping pipette, 20 c.c. 

2 burettes of 50 c.c. capacity. 
A half litre flask. 

Volumetric solutions as directed under volumetric analvsis. 



18 



PRACTICAL EXAMIXATIOX OF THE URIXE. 



If the solutions are made by the student himself, as 
they may be, he should be proyided with a balance 
which will turn with the ^^th of a grain, or 1.3 milli- 
grammes. 



Fig. 1. 



i Mil 



[:.„„Ji 






li^ioo! 



SELECTING A SPECIMEX OF FPvINE. 

In obtaining a specimen of urine for examination, it 
should as far as possible, be a part of 
the whole twenty-four hours' urine, 
as the siDecific grayity, reaction, 
and other properties are well known 
to yary during the twenty-four 
hours, and the only accurate method 
is therefore to take a part of the 
total. But as this is not always 
possible, a portion of that passed in 
the morning before breakfast is 
generally most suitable. And yet 
this is not always the case. Thus, 
when a small quantity of albumen 
is present in urine, it is often in- 
creased after a meal, and some- 
times when there is no trace apparent in the morning 
urine, a little will be found detectible after a meal. 
The same is true of sugar. In Fig. 1 are represented 
forms of glass vessels used for measuring large quanti- 
ties of urine. 



PHYSICAL AND CHEMICAL CHARACTP^R.S. 19 



GENERAL PHYSICAL AND CHEMICAL CHARACTERS OF 
THE URINE. 

Normal urine may be described as a transparent, 
aqueous fluid of a pale yellow (or amber) hue, acid reac- 
tion, specific gravity of about 1020 when passed in the 
average quantity of 1500 cubic centimetres (50 ounces) 
in the twenty-four hours, and possessing an odor which 
can only be described as '^ characteristic " or '^ urinous/' 

Each one of these characters is, however, liable to 
some variation within the limits of health, as well as 
disease, and with these variations we should be thoroughly 
familiar before interpreting a given specimen. 

I. As to Transparency. This, although quite constant, 
can scarcely be considered an essential character of nor- 
mal urine, while on the other hand, it by no means fol- 
lows that because a given specimen of urine is trans- 
parent, it is therefore normal. 

Causes of Diminished Transjmrency. — Diminished trans- 
parency may be due to one of three causes. 1. Even urine 
which is apparently perfectly transparent when passed, 
commonly exhibits a few minutes after standing, a faint 
cloud floating somewhere between the top and bottom, 
which is composed of mucus derived from the genito- 
urinary tract. Mucus itself is also transparent, but 
becomes visible through the presence of so-c^alled 



20 PRACTICAL EXAMINATION OF THE URINE. 

ruucus-corpuscles and epithelium in different stages of 
growth, discoverable by microscoi^ic examination. In 
the urine of females, this cloud is apt to be more dis- 
tinctly visible in consequence of the increased amount of 
epithelium from the vagina, and general increased area 
of the mucus-surfaces in this sex. There is nothing ab- 
normal in the presence of such an amount of mucus as is 
covered by the above description. The effect of alkalies, 
heat, and strong acids is to leave the appearance un- 
changed, but acetic acid may produce a slight increase 
of the opacity. 

2. Normal acid urine may be partially opaque at the 
moment when passed by reason of the presence of the 
earthy phosphates of lime and magnesia. These shortly 
after passing begin to subside, and ^Yithin half an hour 
present an appearance not unlike that of mucus — that of 
a flocculent mass floating somewhere between the top and 
bottom of the vessel. But still later, generally within 
an hour, it has approached the bottom and become a 
sediment, cloudy and bulky, but leaving a transparent 
supernatant fluid. The test of its nature is the addition 
of a few drops of any acid, as acetic, which will cause a 
prompt disappearance of the sediment, if it be the earthy 
phosphate, while the application of heat will increase it, 
such increase being also rapidly dissipated by the action 
of acid. 

The more or less constant presence of the earthy phos- 



PHYSICAL AND CHEMICAI. CHARACTERS. 21 

phates above mentioned cannot be considered abnormal. 
Requiring an acid urine to keep them in solution, a 
diminution of the degree of this may result in their pre- 
cipitation, which is further increased by an alkaline 
reaction. Such diminished acidity and substitution of 
alkalinity always takes place during digestion, and the 
deposit is therefore at such time commonly observed. 

3. Urine is sometimes rendered turbid by the presence 
of the so-called mixed urates of soda, potash, lime, and 
magnesia. The most frequent cause of this precipitation 
in normal urine, is a reduction in the temperature of the 
urine after being passed. Although highly soluble in 
water at the temperature of the body, the urates are 
promptly precipitated from a cold urine, such as would 
be found in a room without fire of a winter's morning. 

As in the case of earthy phosphates, such opacity soon 
diminishes by subsidence of the disseminated urates, 
which become a white or pink deposit, occupying less 
bulk than phosphates. The test of its nature is the ap- 
plication of heat, which quickly causes its dissipation, 
while a deposit of phosphates is increased by heat. 

Pathologically, urine may be opaque or semi-opaque 
from abnormal degrees of the above conditions, or from 
the presence oi pus, which also subsides with a rapidity 
inversely as the quantity of nuicus. If the latter is ab- 
sent or present in small quantity, the subsidence is rapid ; 
if, on the other hand, it is large, subsidence is slow, otten 



22 PRACTICAL EXAMINATION OF THE URINE. 

requiring several hours. The opacity of such urine is 
increased by the application of heat and acids, in con- 
sequence of the precipitation of the albumen which is 
always a constituent of liquor jniris. 

II. As to consistence. In health, urine is never anything 
else but aqueous, that is, dropping and flowing readily. 

Pathologically, it often becomes viscid, glutinous, and 
with difficulty, or not at all, separable into drops. Such 
state may be due to the presence of an excess of pure 
mucus, but most frequently it is caused l)y the action 
upon pus of an alkalinity due to the presence of am- 
monium carbonate, to be again alluded to. 

In the so-called chylous urine of tropical countries, 
also sometimes met here, there is an addition of molecu- 
lar fat, giving a chylous appearance to the urine, and an 
increased consistence. 

III. As to color. While normal urine may be charac- 
terized in general terms as jj^a/e yelloiu, or amber hiied, 
there may be considerable variation in health. Due to the 
presence in solution of the normal coloring matters, it is 
deeper or paler according to the proportion of water dis- 
solving them. After copious libations of beer or w^ater, 
the quantity of urine discharged being large, the color 
is very pale. On the other hand, circumstances which 
diminish the proportion of water within the limits of 
health deepen the color. The complemental relation of 
the skin and kidneys is well known. In warm weather, 



therefore, when the skin is acting freely, the quantity of 
urine is smaller, and it is darker. In winter the quan- 
tity is larger, and its color less deep. In persons from 
whom the respiratory exhalation is less, the urine is like- 
wise less abundant, darker, and vice versa. 

Pathologically, the color of urine may be altered by 
increase or diminution of the normal coloring matters, 
or by the addition of abnormal ones. 

1. The former is also generally due to a change in the 
2)roportion of the coloring matters to the watery constit- 
uents. Thus we have almost an absence of color in the 
copious urines of diabetes, hysteria, and convulsions, while 
we have a high color in the urine of fevers and febrile 
states, chiefly because the quantity of water is diminished, 
but in the latter instance also because of the addition of 
an abnormal coloring matter, the itroerythrin of Heller. 

2. The addition of abnormal coloring matters is seen 
in the instance just mentioned (fevers), in bloody urines, 
in urines containing the coloring matter of bile, in the 
blue and brown urines, of which several instances have 
been reported. 

3. The urine is also colored after the ingestion of cer- 
tain vegetable matters eliminated by the kidneys, as san- 
tonin, which gives a yellow color to urine. 

IV. The reaction, of normal tnixed urine, that is, the 
urine of the entire twcnty-ibur hours, is ahvays arid. And 
generally, specimens of urine passed at any time ot' day 



24 PRACTICAL EXAMINATION OF THE URINE. 

exhibit this reaction, though there is a difference in its 
intensity, while after a meal the urine may become 
neutral or even alkaline. 

The cause of this change in the reaction is still disputed. 
Roberts believes that it is due to an admixture with the 
blood, of the elements of food, which are largely alkaline, 
and that the resulting increased alkalinity affects the reac- 
tion of the urine secreted. Bence Jones contends, that it 
is the demand made on the blood for the elements of the 
acid gastric juice, which thus affects the reaction of the 
urine secreted during digestion. While neither explana- 
tion is altogether satisfactory, the former seems more 
likely to be correct. 

The cause of the acid reaction of the urine is usually 
ascribed to acid soclic phosphate, though it is probably also 
contributed to by other acid constituents, as wHc and 
hipjniric acids, and under certain circumstances, also by 
lactic and acetic acids. 

There is often observed in urine which has been 
standing for a short time an increased degree of acidity, 
which sometimes results in a decomposition of urates, 
and a precipitation, first of acid urates, and then of uric 
acid. This has been ascribed to what has been called 
the acid fermentation, in which it is thought that lactic 
and acetic acids are formed in the decomposition of 
certain organic matters. This has not been altogether 



PHYSICAL AND CHEMICAL CHARACTEJIS. 25 

satisfactorily proven, while the increased acidity is by no 
means constant. 

It is certain, however, that acid urine which has stood 
for some time, and more rapidly in hot weather, exhibits an 
ammoniacal odor, and becomes alkaline in its reaction ; at- 
tending this change of reaction results a semi-opacity with 
a precipitation of a white amorphous and crystalline sedi- 
ment, and often also with the formation of an iridescent 
pellicle on the surface. The cause of these changes has 
been well determined, and has already been alluded to. 
Through the action of mucus and other organic matters 
acting in their decomposition as a ferment, the urea is 
converted into ammonium carbonate by the addition of 
two equivalents of water. Thus : 

CH,N,0-f 2H,0 = (NHJ,C03, 

which gives the odor of ammonia and the alkaline re- 
action. 

The opacity and deposits are due to the precipitation 
of the crystalline triple phosphate of ammonium and 
magnesium, the amorphous phosphate of lime, urate of 
ammonium, and to living vegetable organisms known as 
bacteria. 

V. The specific graviiij as stated may bo put down at 
1020 for an average amount of 1500 c. c. (50 o^.^ in the 
twenty-four hours. But as this amount is by no moans 



26 PRACTICAL EXAMINATION OF THE URINE. 

fixed, while the amount of solid matter remains about the 
same, the specific gravity must vary accordingly. In 
cold weather, when the skin is not acting, and after 
copious use of water and diuretics, the specific gravity 
may descend to 1005 within the limits of health. 
But, where perspiration is copious, or a drain of water 
from the economy takes place through some other 
channel, the urine becomes concentrated, and may be 
1028 or more in specific gravity. 

PaiJiologlcaUy, the specific gravity of urine is increased 
or diminished, but no results can be relied upon, unless 
they be based upon a consideration of the entire quantity 
passed in the twenty-four hours. The specific gravity is 
increased in diabetes mellitus^ where it sometimes reaches 
1050. A specific gravity of more than 1028, if it attend 
a copious urine, should excite suspicion of diabetes, and 
calls for sugar tests. The specific gravity is also in- 
creased in the first stage of the acute fevers, in consequence 
of the increased amount of solid matters excreted ; and 
in the first stage of acute Bright's disease, from tlie 
presence of blood, the higher specific gravity of the 
latter raising that of the mixed fluid. The specific 
gravity is diminished in hysterical and spasmodic hy- 
druria, though here it attends a proportionate increase 
of water and is not of much practical significance. In 
all forms of Bright' s disease, except the stage of acute 
nephritis referred to, there is a tendency to lowering of 



PHYSICAL AND CHP]M1CAL CHARACTEPwS. 



27 



specific gravity from the diminished proportion of urea. 
Particularly is such reduction of specific gravity signifi- 
cant when it attends a diminished quantity of urine. 
In a general way, the presence of albumen and sugar 
being eliminated, variations in the specific gravity of 
urine point to variations in the amount of urea present ; 
lower specific gravity of mixed urine means less urea. 

To determine specific gravity, the so-called urinometer 
is almost invariably used, and though less accurate than 
the picnometer (e, Fig. 2) and balance, is still sufFi- 

FiG. 2. (From Harley.) 



IS' 




ciently so when carefully constructed, l^vorv urinom- 
eter should first be tested witli distilled water ai (K)""^ F. 



28 



PRACTICAL EXAMIXATIOX OF THE URINE. 



(15.54 C.) into which it should sink to the mark or 
1000. In their graduation the lines indicating the de- 
grees should gradually approach each other as the bulb is 
reached, because allowance must be made for the weight 
of the stem above water. 

The English-made urinometers, about 5 inches long 
(Fig. 2 c), are generally accurate, but the short German 
instruments (3 inch) are very convenient for small 
quantities of urine. In the little urinometer of Heller 
Fig. 3. (Fig. 3), much used in Vienna, in 
which the " sink " consists of leaden shot, 
the graduation of Baume is retained, in 
which one degree corresponds with seven of 
the ordinary scale. Thus 1001 = 1007, 
1002 = 1014, and so on. Especial care 
should be taken in testing these instruments, 
as a slight variation in them indicates a 
large one by the ordinary scale. The writer has in 
his possession an instrument of this kind which recorded 
the specific gravity of a given specimen of urine 1004, 
that is, 1029 by the ordinary scale, of which the specific 
gravity by a long-tried English instrument was found to 
be 1019. And on testing the former with distilled 
water, it was found to sink, not to 1000, but to 1001 + , 
proving its inaccuracy. More recently a urinometer has 
been furnished in Vienna even slightly shorter than the 
original of Heller, in which the ordinary scale is re- 




PHYSICAL AND CHEMICAL CHARACTP^RS. 29 

tained on an ivory stem within the tube, and the " sink '' 
contains mercury instead of shot, apparently altogether 
more carefully made. These, so far as I have tried 
them, I have found accurate. 

The cylindrical glass vessel usually supplied with the 
urinometer, or a sufficiently large test-tube, should be f or 
^ filled, the urinometer introduced, and when at rest, the 
specific gravity read off. The cylinder or test-tube should 
not be too small in relation to the urinometer, lest in 
consequence of the capillary attraction between the latter 
and the walls of the cylinder, the urinometer should not 
sink as low as it ought. For the same reason the uri- 
nometer should not be allowed to impinge against one 
side of the glass. If the quantity of urine be too small 
sufficiently to fill the cylinder, it may be diluted with a 
quantity of distilled water sufficient to fill the cylinder 
to the required height. From the sp. gr. of this mix- 
ture may be calculated that of the urine. Thus suppose 
it is necessary to add four times as much water as urine 
to enable us to use the urinometer, that is, make five 
volumes, and the specific gravity of the mixed fluid is 
1004, then that of the urine would be 1004 X 5 = 1020. 

VI. Quantity. The average amount of urine in the 
twenty-four hours is put down at 1500 e. c, or about 50 
fluid ounces. But enough has already been said to allow 
the inference that there is also much variation within the 
limits of health. All that has been said of color and 

3 



30 PKx\.CTICAL EXAMINATION OF THE URINE. 

specific gravity in this respect is true of the quan- 
tity of urine, though in an inverse ratio. That is, in 
health, diminished intensity of color and diminished 
specific gravity correspond with increased quantity of 
urine. It is with regard to quantity that the comple- 
mental relation so well known to exist between the skin 
and kidneys most palpably shows itself, the increased 
action of the former causing diminished quantity of 
water separation by the latter, and vice versa. In de- 
ranged conditions, it is the absence of this relation of 
color and specific gravity to quantity which gives sig- 
nificance to either. 

Pathologically. In diabetes, and hysterical and con- 
vulsive conditions, the quantity of urine is increased, in 
the former, however, with increased specific gravity, and 
in the latter with diminished. In cardiac hypertrophy, 
in common with all conditions of increased blood-pres- 
sure, in w^hich we include ingestion of large amounts of 
water, the peripheral action of cold, etc., there is an 
increase of water, and a corresponding reduction in spe- 
cific gravity and color. 

In all forms of Bright's disease, except in the cirrhotic 
and albuminoid kidneys, there is a tendency to diminished 
secretion of urine. Towards the fatal termination, how- 
ever, it is observed even in these affections. Any marked 
diminution of urine in these affections, particularly if it 



PHYSICAL AND CHEMICAL CHARACTERS. 31 

be attended by a low specific gravity, which means 
diminished urea, becomes a portentous symptom. 

In acute fevers and inflammatory affections, the quan- 
tity of urine is very constantly diminished until conva- 
lescence sets in, when there is generally observed a 
marked increase in the secretion of urine, which, in com- 
mon with the profuse perspiration often observed at the 
same time, was long ago characterized by the word 
" critical." 

' VII. Of the odor, little more can be said than that it 
is "peculiar" or "characteristic" in health. There is, 
however, appreciable diflerence in its intensity, as most 
have observed in their own cases. Concentrated urines 
always exhibit what is described in common language 
as "strong odor." This is undoubtedly due to urea, 
though the peculiar odor of urine is not ascribed to 
urea, but rather to the minute quantities of phenylic, 
taurylic, and damoluric acid which are found in it. 

Urine which has been standing exposed in warm 
weather, acquires an odor which is at once putrescent 
and ammoniacal, the former from decomposition of mucus 
and other organic matters, the latter from the ammonium 
carbonate derived from the urea. The former is pre- 
dominant when a large amount of organic matter is 
present, and is often observed in destructive disease of 
the kidney or its pelvis, and especially of the bhuKlor. 

The odor of urine is very promptly inlluencod by that 



32 PRACTICAL EXAMINATION OF THE UKINE. 

of substances separated by the kidney from the blood, 
illustrated by the well-known phenomenon of the odor 
of violets in the urine of persons taking turpentine. The 
odor of cubebs, copaiba, and sandalwood oil is promptly 
communicated to the urine of persons taking them. So, 
too, the use of certain vegetable foods promptly influ- 
ences the odor of the urine. Among these asparagus is 
prominent. 

In disease, except the increased intensity of the charac- 
teristic odor in concentrated urines, the putridity alluded 
to, and a siueetish smell which often attends the presence 
of sugar in the urine, there seem to be no modifications 
of this "characteristic'' odor of urine. 

To Determine the amount of Solid Matters in the Twenty- 
four hours' Urine. 

Knowing the quantity of urine passed in the twenty- 
four hours, and its specific gravity, an approximation to 
the quantity of solid matters, and thence that of water, 
may be readily obtained by multiplying the last two fig- 
ures of the sp. gr., by what is known as Trapp's co- 
efiicient — 2.33. This will give approximately the num- 
ber of grammes, in the 1000 c. c. (33 J oz.). 

Thus, suppose the twenty-four hours' urine to be 1200 
c. c.,.and the sp. gr. to be 1022, then 

22 X 2.33 = 51.26 grms. in 1000 c. c. 



SOIJD MATTERS. 



But the total quantity of urine in twenty-four hours is 
1200 c. c, therefore it will contain more than 1000 c. c. 
contain. Hence, 



1000 : 1200:: 51. 26 :a^ = y^-?lili^-= 61. 51 grns. (948.09 grs.) 

1000 ^ ^ ^ 



Now the normal amount of solid matters in the twenty- 
four hours is about 70 grammes (1080.1 grs.), showing 
that ii4 this instance rather less than the normal quantity 
was separated. In this manner valuable information 
bearing upon diagnosis and prognosis may be obtained 
in a few seconds. The most striking variations are ob- 
served in diabetes and Bright's disease, the former of 
increase in solids by addition of sugar, the latter in 
diminution by loss of urea. 

While this method of arriving at the solids is not suffi- 
ciently accurate for scientific use, it answers for ordinary 
clinical purposes. 



34 PRACTICAL EXAMIXATIOX OF THE URINE, 



THE STUDY OF THE DIFFERENT CONSTITUENTS 
OF URINTE IN HEALTH AND DISEASE. 

In the examination of a specimen of urine, the follow- 
ing are the steps which will be found most convenient in 
actual practice. Observe : 

I. The quantity passed in twenty-four hours. 
II. Color and transparency. 

III. Odor. 

IV. Reaction. 

V. Specific gravity. 
VI. Presence or absence of. sediment, its quantity, 
and characters. 
In all cases, whether the sediment be appreciable 
or not, a portion of the flaid should be set aside in a 
conical glass vessel for twelve hours, with a view to 
collecting the sediment for mia^oscopical examination. 
The remaining, or supernatant fluid, filtered, if neces- 
sa7'yj should then be further examined. 

Organic Constituents, 

VII. Presence or absence of albumen. 

VIII. Presence or absence of sugar. 

r Normal. 
IX. Coloring matters. < ^ ^ ^ 

( Abnormal. 



INORGANIC CONSTITUENTS. 35 

These three are made to precede normal constit- 
uents, because they must form a part of every exami- 
nation. 

X. The biliary acids. 
XI. Leucin aud tyrosin. 
XII. Urea. 
XIII. Uric acid. 



Inorganic Coiistituents, 



XIV. Chlorides. 

XV. Phosphates. 
XVI. Sulphates. 



a. Earthy phosphates. 

b. Alkaline 



Examination of Sediment Microscopically and Chemically. 

I. Unorganized deposits, including crystals and amor- 
phous deposits. 

II. Organized deposits, including anatomical elements, 
such as casts, epithelium, pus, blood-corpuscles, etc. 

III. Other morphological elements, as fungi, pigment- 
ary particles, granular matter, extraneous substances, etc. 

Nos. I, II, III, IV, V, VI require no further expla- 
nation than is involved in the consideration of the ''gene- 
ral physical and chemical characters." 



36 PRACTICAL EXAMINATION OF THE URINE. 

Organic Const Ituoits, 

VII. To Detect the Presence of Albumen. In 
all instauces where the urine used for testing is not 
perfectly clear, it should be filtered before applying 
the tests. This may be done in a few minutes by means 
of filtering-paper and a funnel. 

a. The test by Heat. A test-tube is filled to ^ to ^ its 
depth Avith clear urine, to w^hich, if it be not of dis- 
tinctly acid reaction, a few drops of acetic acid are 
added, and the fluid boiled over a spirit-lamp. If an 
opacity result, the slightest degree of which becomes 
visible in a clear urine held in a beam of sunlight,, 
it is due either to albumen or earthy phosphates. If 
the latter, it promptly disappears on the addition of a 
few drops of nitric acid; if albumen, it is permanent. If 
further confirmation is desired, to the boiling urine 
quickly add half as much of the stronger potash solu- 
tion (7, p. 16), when the albumen is dissolved, and the 
earthy phosphates again separate in flocculi. 

If the urine has not been filtered, and is opaque from 
the presence of amorphous urates, the first eflfect of the 
application of heat is to clear up the fluid, and as the 
temperature is increased, the albumen, if present, is pre- 
cipitated. 

Acetic acid is preferred to nitric for acidulating the 



ORGANIC CONSTITUENTS. 



37 



Fig. 4. 



Fig. 5. 





urine, because if the quantity of albumen is small it may 
hold it in solution by nitric acid. 

b. The Nitric Acid test is best applied according to 
Heller's method. Fill a test- 
tube to the depth of 1^ to 2 
inches with clear urine (for this 
purpose one of the test-tubes 
with a foot, Fig. 4, is most con- 
venient), and allow about 3 c. c, 
or f 3ss. to f 5j of pure colorless 
nitric acid to trickle down the side 
of the inclined glass to the bot- 
tom, so as to underlie the urine. 

If albumen is present, there appears at the point of con- 
tact, between the urine and nitric acid, a sharp ivhite band 
or zone of varying thickness, according to the quantity of 
albumen present. 

Precautions. 1. Much difficulty is often experienced in 
permitting the acid to flow from the pipette sufliciently 
slowly — that is, it will either not flow at all, or the finger 
in the effort to attain it is suddenly raised so much as to 
permit a sudden flow of the acid into the urine, which 
interferes with the success of the test. This difficulty is 
readily overcome by rotating the pipette covered by the 
end of the index-finger, between the middle finger and 
the thumb, whereby the flow may be easily controlled. 

2. A somewhat similar white zone is fornuHl bv the ac- 



38 PRACTICAL EXAMINATION OF THE URINE. 

tion of nitric acid ou the mixed urates if present in excess, 
by ^vllich the more insoluble acid urates are thrown down. 
This zone might be mistaken for that of albumen ; but 
the acid urates begin to appear, not so much at the border 
between the urine and acid as higher up ; nor is the zone 
on the upper surface so sharply defined, but more irregu- 
lar. By HoflTmann and Ultzmann the appearance is 
compared to the "cloudlike curling of rising smoke." 
Further, this layer if caused by urates is easily dissipated 
on the application of heat, although some care is neces- 
sary in this application lest in ebullition the ring be com- 
mingled with the entire mass of fluid and thus lost to 
view, although not actually dissolved. After some hours 
have elapsed these amorphous acid urates are completely 
decomposed by a further action of the nitric acid, and 
uric acid is then deposited as a characteristic crystalline 
sediment. When large quantities of albumen are present, 
there is never any difiiculty with either test, but for small 
amounts of albumen this form of nitric acid test has 
proved in my hands by far the most delicate, quantities 
of albumen so small as to be altogether inappreciable by 
the heat test, being distinctly demonstrated. 

3. This method obviates the possibility of two further 
sources of error pointed out by Bence Jones, first, that if 
albuminous urine be acidified by a small quantity of acid, 
as a drop or two, no precipitation of albumen takes place, 
while if too large a quantity as an equal bulk of acid be 



ORGANIC CONSTITUENTS. 39 

added, the mixture in like manner remains perfectly 
clear. Roberts says he has known the latter fallacy to 
cause the concealment of albumen in the urine for months 
in a case of Bright's disease. 

4. Occasionally, also, it happens that a urine is so 
highly concentrated — so highly charged with urea — that 
the simple addition of nitric acid causes a precipitation 
of crystals of nitrate of urea. But these are readily 
distinguished from albumen by their solubility by heat, 
and by their appearance under the microscope, which 
exhibits them made up of six-sided rhombic tablets. 
Such urine is always of high specific gravity. 

5. If carbonic acid be abundantly present in urine, 
either free, or combined with ammonia as in the alkaline 
fermentation, or with soda or potash, during the adminis- 
tration of alkaline carbonates or salts of the vegetable 
acids, the addition of an acid liberates it with efferves- 
cence. Under ordinary circumstances, this does not inter- 
fere with the test ; but if the quantity of carbonate of am- 
monia be venj large, as is the case in some old urines, and 
the quantity of albumen small, the effervescence is so 
great as to make the nitric acid test impossible ; while 
the amount of acetic acid required to secure an acidity 
sufficient to permit the use of the heat test may be so 
great as to completely hold in solution the small ([uantlty 
of alhumeu. Such didiculty is further increased by the 
fact that these alkaline urines are always more or less 



40 PEACTICAL EXAMIXATIOX OF THE UEIXE. 

cloudy, and cannot be cleared up by ordinary filtration. 
Under these circumstances, boil the urine with a fourth 
part of its yolunie of the stronger solution of caustic 
potash, and filter. If the filtrate is still not quite clear, 
add one or two drops of the magnesian fluid ; warm 
again, and filter. The fluid is then always clear and 
transparent, and, after being carefully acidulated with 
acetic acid, will show the smallest trace of albumen. 
But it can be made eyen more apparent ; if to the fluid 
acidulated with acetic acid, a few drops of a solution 
of yellow prussiate of potash be added, the mixture 
shaken and allowed to stand for a few minutes, white 
flakes of separated albumen will soon be seen at the 
bottom (Hofi'mann and Ultzmann). 

When nitric acid is thus allowed to underlie normal 
urine, there appears between the urine and the acid a 
brown ring which grows in intensity on standing, and is 
due to the action of the acid on the coloring matters. In 
consequence of this fact, when the urine is highly charged 
with coloring matters, as it often is in feyer cases, the 
albumen precipitated at the same place is similarly tinted. 
If there is much indican present in the urine, a rose-red 
or yiolet tint may be communicated to the albumen; if 
much blood-coloring matter, a brownish-red, and if unde- 
composed biliary coloring matters, a green hue. 

Other Tests for Albumen. Xothing is said of the numer- 
ous other tests for albumen, such as carbolic acid, picric 



ORGANIC CONSTITUENTS. 41 

acid, corrosive sublimate, sulphate of copper, alcohol, 
etc., because they are either inapplicable, or less accurate 
than the methods described. With regard to picric acid, 
however, which has been most recently lauded, I have 
experimentally determined that the heat and nitric acid 
tests show smaller quantities of albumen in urine than it 
does, while my friend. Prof. H. P. Bowditch of Boston, 
has arrived at the same results, by experimenting with 
carefully prepared solutions of egg albumen of known 
strength.* 

Quantitative Estimation of Albumen. It is a matter of 
extreme importance in the course of Bright's disease that 
we should be able to compare the quantity of albumen 
contained in the urine from day to day. The only accu- 
rate method is by precipitation by acetic acid and boiling, 
separation by filtration, drying and weighing by delicately 
accurate balances, the weight of the filter having been 
previously determined. This, however, involves too much 
time for the busy practitioner, and we must fall back on 
one of the approximative methods. The best known of 

■^- The method of using picric acid is to make a saturated 
water}^ solution (water takes up a very small quantity), place 
some urine in a test-tube, and allow the picric acid solution to 
fall into it drop by drop, when each drop as it passes tlirmiL:.-!! 
the urine is followed by an opaque white cloud. The test is 
very striking and beautiful, when the quantity oi' allninuMi is 
suiKcient to permit its a}q)licatiiui. See note at end of volume. 



42 PRACTICAL EXAMINATION OF THE URINE. 

these is to boil a given quantity of urine in a test-tube, 
add a few drops of nitric acid, and stand aside for twenty- 
four hours. The proportion of bulk occupied — one-fourth, 
one-eighth, a trace, etc., is tised to indicate the quantity 
of albumen. Greater accuracy is obtained by previously 
filtering the urine of urates, epithelium or extraneous 
matter which may unduly increase the bulk of deposit 
on standing. 

More definite but perhaps scarcely more accurate is 
the approximative quantitative estimation by means of 
Heller's nitric acid method as given by Hoffmann and 
Ultzmann. According to them, if the white zone of 
albumen has the depth of a crow-quill, is delicate and 
faintly white in color, has no granular appearance, and 
appears clearly defined only when placed against a dark 
background, the quantity is less than half of one per cent 
If, however, the zone of albumen appears granular and 
flocculent, and sinks in more or less lumpy masses to the 
bottom, and when by stirring the albumen by means of 
a glass rod the mixture assumes the consistence and 
appearance of sour cream, then the quantity is very large, 
one to two per cent. 

VIII. To Detect the Presence of Sugar. Of 
the large number of tests extant for the presence of 
sugar, only those are given which have borne the trial of 
experience, and it is suggested that for practical pur- 
poses the student should select some one of these, and 



ORGANIC CONSTITUENTS. 43 

accustom himself to its use and the modifications in 
results to which all are more or less subject. I am con- 
fident that much of the difference of opinion with regard 
to the reliability of the different tests is due to the fact, 
that those claiming it have had more experience with 
the particular test which they recommend. Thus, in 
Germany, Moore's test is evidently the favorite one, 
while in my own hands, the old Trommer's test gives most 
satisfaction, simply because I have become accustomed 
to its use. But it is necessary to be familiar with 
more than one test, because cases of doubt constantly 
arise where the evidence of one is insufficient. Although 
Briicke has shown that sugar is present in very minute 
quantity in normal urines, yet the amount is so slight 
as to escape detection by the ordinary tests. 

Specific Gravity and Quantity as a test. The specific 
gravity alone, when 1030 or more, affords a presumption 
of the presence of sugar, and if at the same time the 
urine is very pale, and far exceeds 1500 c. c. (50 fl. oz.) in 
twenty-four hours, the probabilities are much increased. 
These facts at least call for the use of other tests to 
determine the question. Further, if the quantity of 
sugar is very large, a sweetish odor and taste is com- 
municated to the urine. 

In using any of the folloiciixj frsir^, if alhui)it)i is at all 
ahundantly present J it should first he removed by boili)Hj mid 
filtration. 



44 PRACTICAL EXAMINATION OF THE URINE. 

Moore's Test. Moore's test depends upon the fact that 
grape-sugar, with which diabetic sugar is identical, 
undergoes decomposition by boiling in contact with 
caustic alkali. To a small quantity of urine in a test- 
tube, add half as much liquor potassa or liquor soda and 
boil. If sugar is present, a yellowish-brown color will 
soon make its appearance, which becomes more intense as 
the boiling is continued, and which will be the deeper 
the larger the proportion of sugar, becoming finally 
almost black if the quantity is very large. The colora- 
tion is due to the formation, first, of glucic, and finally of 
melassic acid, which, however, remain in solution. The 
flaky precipitate which is observed after the addition 
of the alkali, and is increased on the application of heat, 
is made up of the earthy phosphates, which may be 
filtered ofi" before the heat is applied if very abundant. 

If now to the colored fluid a few drops of nitric acid 
he added, the hrown coloration disappears, and the odor of 
burnt molasses is developed, and in this we have Heller's 
modification of Moore's test. 

Precautions, 1. Solutions of soda and potash are 
liable to become impregnated with lead, either from 
being kept in flint-glass bottles, or from the glazed 
earthenware vessels in which, during preparation, they 
are evaporated. Such contamination always causes the 
production of a brown and black color when boiled 
with organic matter containing sulphur, due to the 



ORGANIC CONSTITUENTS. 45 

formation of sulphuret of lead. This error may be 
avoided by first ascertaining the purity of the alkaline 
solutions, and afterwards keeping them in green glass 
bottles. 

2. If the urine exhibits already a high color, which 
is, however, very rare with diabetic urines, the coloring 
matters may be precipitated by solution of acetate 
(sugar) of lead, which does not at all interfere Avith the 
sugar, although the subacetate of lead throws down also 
a small quantity of sugar. 

3. The coloring matters of bile in urine, either 
when pure, or decomposed (that is, when they respond 
neither to Gmelin's or Heller's test), produce a broivu 
color with liquor potassa or soda ivUhoiU the application 
of heat. 

4. According to Bsedecker, a substance is sometimes 
found in urine which he calls alkapton, w'hich when 
strong solutions of alkali are added produces a brown 
discoloration from above downward. This, according to 
him, also reduces the salts of copper, but does not afiect 
the bismuth salts. 

The Copper Tests. — Trommer's test. The copper tests 
depend upon the power which grape-sugar possesses of 
reducing the oxide of copper in common with other 
metallic oxides, as silver, gold, etc., to a lower stale of 
oxidation. 

In Trommcr's test, the oxide of co})per is set free at tlie 



46 PRACTICAL EXAMINATION OF THE URINE. 

time of its application by liquor potassse or sodse in ex- 
cess. A drop or two of a solution of cupric sulphate of 
almost any strength (say 1 to 10), is added to the sus- 
pected urine, and then liquor potassse or sodae equal to 
half the total volume. On first adding the alkali there 
is immediately liberated, in addition to the earthy phos- 
phates, a blue precipitate of hydrated cupric protoxide, 
ivhicJi, if sugar is present, is redissolved on adding more 
alkali, producing a beautiful blue transparent liquid. 
If, on the other hand, no sugar is present, the fluid will 
not be thus blue after the addition of the copper and 
alkali, but exhibit rather a turbid greenish hue. This, 
however, is not alone relied upon, but the mixture is 
boiled, and if sugar is present, a copious yellow precipi- 
tate of hydrated cupric suboxide takes place, which sub- 
sequently loses its water and becomes the red suboxide, 
which soon forms a close adhesion to the bottom or sides 
of the test-tube. 

Precaidions. 1. Albumen, if present, must always be 
removed, as it interferes with the reduction of the 
copper. 

2. While the fluid must be made to boil for perhaps 
half a minute, the precipitate should take place without 
prolonged boiling, as numerous organic substances other 
than sugar will reduce the salts of copper by prolonged 
boiling. 

3. The flocculent precipitate of earthy phosphates 



ORGANIC CONSTITUENTS. 47 

should not be mistaken for the suboxide of copper; it is 
either transparent or of a pale greenish hue. On the other 
hand, a mere change of color is not sufficient. There 
must be an actual yellow or red precipitate. If it be 
desired to eliminate this source of error altogether, it 
may be done by adding the potash solution, and filtering 
before adding the copper. 

4. Carefully conducted experiments by Dr. Beale 
have shown that if the urine contain ammonium chloride 
(even in very small quantity), ammonium urate or 
other ammoniacal salts, the cupric suboxide will not be 
precipitated if only a small quantity of sugar is present. 
Under these circumstances, unless there be a considerable 
quantity of the above salts present, in which case the 
blue color will remain, the mixture will change to a 
brownish hue upon boiling, but no ojxdescence or jyrecijyi- 
tate of copper will occur. Prolonged boiling with pot- 
ash, of urine containing ammonium compounds, will 
drive off the latter, which may be recognized by its char- 
acteristic fumes, after which the copper tests will again 
become operative for the smaller quantities of sugar. 
But under any circumstances such urine should be sub- 
jected to the bismuth or fermentation tests, or both. 

Other Coj)j)er Test Solutions. — Fehlincfs ainl Favfs 
fluids. It has been stated that when an alkali is added to a 
solution of sulphate of co})per an abundant })roripiiate oi' 
hydrated cupric protoxide is thrown down. This is not 



48 PRACTICAL EXAMINATION OF THE UETNE. 

dissolved by any excess of alkali added, but if some 
organic matter is added or happens to be present, an 
excess of alkali dissolves the protoxide. It is for this 
reason, that if sugar happens to be present in a suspected 
fluid to which these have been added, the precipitated 
protoxide is dissolved and a clear blue fluid results. 

These facts enable us to construct a fluid which will 
hold the protoxide of copper in solution ; but in selecting 
an organic substance one must be chosen which will not 
reduce the oxide of copper as does sugar, else it will 
make our test inoperative. Such a substance is tartaric 
acid, which is usually employed. 

Of the numerous test fluids employed, only Fehling's, 
and Dr. Pavy's modification of it, are given, since these 
are most convenient in practice, and serve also for quan- 
titative estimation. The one or the other may be used, 
as it is preferred to work with the English or metric 
system. 

Fehling^s solution. 34.639 grammes (534.479 grains) 
pure crystallized sulphate of copper are dissolved in 
about 200 grammes (3086 grains) distilled water; 173 
grammes (2669.39 grains) chemically pure crystallized 
neutral tartrate of soda in 500 to 600 grammes (7715 to 
9258 grains), solution caustic soda of specific gravity 1.12, 
and pour little by little into this basic solution, the copper 
solution. The clear mixed fluid is diluted to 1 litre 
(2.1 pints). 



ORGANIC CONSTITUENTS. 49 

10 c. c. (162 minims) of this solution will be reduced 
by .05 grammes, or 50 milligrammes (Jllo grains) 
diabetic sugar. If the copper solution is to be kept 
some time, it is absolutely essential that it should be 
placed in smaller (40-80 grammes) bottles, sealed and 
kept in the cellar. 

Pavy\s solution consists of 

Cupric Sulphate, . . . 320 grains. 

Neutral Potassic Tartrate, . . 640 grains. 

Caustic Potash, .... 1280 grains. 

Distilled Water, .... 20 fluid ounces. 

The solution is made in the same manner as Fehling's, 
and 100 minims correspond to ^ grain grape-sugar. 
These solutions serve equally Vv^ell for qualitative and 
volumetric testing, but if it is simply desired to have a 
solution for the former purpose, it may be made by 
pounding together 5 grains (.324 grammes) cupric sul- 
phate, 10 grains (.624 grammes) neutral potassic tar- 
trate, and dissolving in 2 drachms (7.4 c. c.) liquor po- 
tassai. The usual blue fluid results. 

To use. In using either of the above solutions for 
qualitative testing, a small quantity should be placed in 
a test-tube and boiled alone for a tew seconds, because 
the fluid, in course of time, decomposes, and as a result 
the copi)er is reduced, and a precipitate takes place by 
boil in o; it alone. 



50 PRACTICAL EXA^riXATIOX OF THE URINE. 

If this occurs, a new supply raay be obtained, or a 
little more soda may be added, the fluid filtered, and it 
is again ready for use. After the solution is brought to 
boil, the suspected urine is added, drop by drop. If 
sugar is present in any quantity, the first few drops will 
usually cause the yellowish precipitate, but the dropping 
may be continued until an equal volume of urine is 
added, when the mixture is again brought to boil. If 
no precipitate occurs no sugar is present. 

The same precautions laid down with regard- to 
Trommer's test are here to be observed. 

Baiger\i Bismuth test consists in the addition to urine 
in a test-tube of half its volume of liquor potassie or 
sodie, then of a pinch of the ordinary subnitrate of bis- 
muth, shaking and boiling for a couple of minutes. The 
sugar possesses the power of reducing the salts of bis- 
muth, and if sugar is present, the black metallic bismuth 
will shortly be deposited on the side of the test-tube. If 
the quantity of sugar is small, the bismuth will assume 
a grayish hue. 

This is ini excellent test, and the one I usually employ 
to confirm the results of the copper test. Xo other sub- 
stance than sugar is supposed to reduce bismuth salts. 

The Fermentation teM. Perhaps the most reliable of 
all tests for the presence of sugar, is the fermentation 
test, but being somewhat troublesome, is less suitable 
to the practitioner as an everyday test. The most cou- 



ORGANIC CONSTITUENTS. 



51 



Fig. 6. (From Harlcy.) 




venient method of its application is as follows: A test- 
tube of large size is provided 
with a tightly fitting perforated 
cork, through which one limb of 
a bent glass tube long enough 
to reach nearly to the bottom 
is passed. A small quantity of 
ordinary baker's or brewer's 
yeast (about a fluid drachm, or 
3 to 4 c. c.) is placed in the tube, 
which is then filled with urine, 
tightly corked, allowing no air 
to remain, and placed in a vessel 
which may be filled with tepid 

water, in a moderately warm room. If sugar is present 
evidences of fermentation will soon present themselves in 
the formation of carbonic acid, which will force the fluid 
out of the bent tube into the glass, arranged for its recep- 
tion. If carefully performed this test is thoroufjJily reliable. 

Quantitative Estimation of Sugar. So important is a 
knowledge of the daily change in the quantity of sugar 
in the urine of a case of diabetes, that it may bo laid 
down that some kind of quantitative estimation from 
day to day is absolutely necessary. 

1. Approximative Estimation. While the sped tie gravity 
determined from the twenty-four hours' urine may serve 
to o;ive a o-eneral idea of the increase or (liniiniuiiMi of 



52 PRACTICAL EXAMIXATIOX OF THE URINE. 

the amount of sugar, in consequence of the complex 
composition of the urine it cannot be relied upon even 
for approximate estimation, as it might be in a simple 
watery solution of sugar. 

To those who habituate themselves to ^Moore's test, 
the method of Vogel recommends itself by its simplicity 
and brevity. As the result of trial, Vogel has deter- 
mined that solutions of grape-sugar, when boiled with 
half their bulk of liquor potass?e, exhibit the following 
changes of color: A 1 j^er cent, solution becomes ca/ianj 
yellow; a 2 per eent. a dark amber; a 5 per cent, a dark 
Jamaica rum (^?); and a 10 per cent, a dark black-brown , 
and opaque, while all solutions of a less percentage are 
more or less transparent. 

With a pale urine, in the hands of one accustomed 
to this test, if the specific gravity be also regarded, toler- 
able accuracy may be obtained. It should certainly be 
employed rather than none at all. 

b. Bobertss Fermoitation test is based on the fact that 
diabetic urine loses in specific gravity after fermentation 
is completed. Dr. Eoberts, of Manchester, England, has 
shown by careful experiments, that every *' degree" in 
specific gravity lost in fermentation, corresponds to 1 
grain of sugar per fluid ounce. Thus, if before fermen- 
tation the specific gravity of a given specimen is 1050? 
and after fermentation it is 1020, it will have contained 
30 grains to the fluid ounce. The method recommended 



ORGANIC CONSTITUENTS. 53 

by Dr. Koberts is as follows: About four ounces of the 
saccharine urine are put in a 12-ounce bottle, and a 
lump of German yeast,* about the size of a small wal- 
nut, is added. The bottle is then covered with a nicked 
cork, to permit the escape of the carbonic acid, and set 
aside on a mantel-piece, or other warm place. Beside it is 
placed a tightly corked 4-ounce vial, filled with the 
same urine, bu,t without any yeast. In eighteen to 
twenty-four hours fermentation will be complete, and 
the scum cleared off or subsided. The specific gravity 
of the decanted fermented urine is then taken ; at the 
same time, that of the unfermented urine, and a compari- 
son made. While some time is here required to com- 
plete the fermentation, yet, as Dr. Roberts says, the 
preparations can be made by the patient himself or 
friends, and each day, when the physician makes his 
visit, he has only to make the comparison. 

2. Volumetric Process. The exact quantitative methods 
are those by Fehling's or Pavy's solutions. That recom- 
mended by Pavy is by far the most convenient in prac- 
tice, requiring a hundred-minim graduated pipette,f a 

•^ German yeast is not easily obtainable in tliis city, but the 
ordinary yeast answers as well. 

f For some time it was impossible for me to get a minim 
pipette in this city. Finally I found they were to be had of 
W. H. Pile, northwest corner of Passyunk Avenue and Catha- 
rine Street, who ])repares them with great care. 

5 



54 PKACTICAL EXAMINATION OF THE URINE. 

measuring glass, spirit-lamp and stand, and porcelain 
capsule. 

In an ordinary case of diabetes, the urine contains too 
much sugar to be tried, unless diluted with a known 
quantity of water. Generally it suffices to dilute it with 
two to four times its bulk of water, according to the 
amount of sugar it is suspected to contain from the 
specific gravity. 

One hundred minims of Pavy's solution, which, it 
will be recollected, are just decolorized by half a grain 
of sugar, are now measured out into a porcelain capsule. 
Into this a fragment of caustic potash, about twice the 
size of a pea, is dropped for the purpose of causing the 
reduced oxide to fall in a denser form, so that the liquid 
may remain clear, and allow the change of color to be 
more readily seen. The capsule is then placed over the 
flame of a spirit-lamp or gas, on a retort stand, or better, 
on a piece of iron gauze, adapted to the top of a stone- 
ware cylinder, as arranged in the cut. Fig. 7. The cyl- 
inder protects the flame from draught, and the gauze 
distributes and regulates the heat. 

The one hundred minim pipette is now filled with the 
mixture of urine and water, and as soon as the fluid in 
the capsule begins to boil, the contents of the pipette are 
allowed to fall drop by drop into the test solution in the 
capsule, which must be kept boiling, and moved about 
by tilting with a glass rod, until all the blue color is 



OKGANIC CONSTITUENTS. 55 

gone. All trace of blue should be removed, and a little 
experience will enable even the beginner to note the exact 
point. If the deposit falls slowly, the process may be 

Fig. 7. (From Pavy.) 



Stopped for a few minutes until it has subsided, when by 
tilting the capsule a thin layer of the fluid may be ex- 
amined over the pure white porcelain, and thus any 
remaining coloration detected. We then note how 
many minims of the urine mixture have been used to 
decolorize the one hundred minims of test solution, 
thence the number of minims of pure urine, and thence 
the quantity in the whole twenty-four hours. 

Thus, suppose the quantity of urin(^ in twonty-four 



56 PRACTICAL EXAMINATION OF THE URINE. 

hours to be 100 ounces, some of which was diluted four 
times — that is, of 100 minims of the mixture 20 were 
urine ; suppose, further, that 80 minims of this mixture 
exactly reduced the 100 minims of solution representing 
the half grain of sugar. Then one-fifth only being urine, 
Ave have learned that 16 minims of urine contain half a 
grain of sugar, and from this that an ounce contains 15 
grains and 100 ounces or the twenty-four hours' urine, 
15 X 100 = 1500 grains. 

Fehling's solution may be used in precisely the same 
manner, using however the metric system of measure- 
ment and operation, and obtaining results in the same 
system. Either solution may be dropped from a burette 
in a manner to be described in the volumetric analysis 
for urea, etc. 

IX. Coloring Matters. The pathological signifi- 
cance of the coloring matters has recently assumed such 
importance that their consideration commands interest 
next to that of albumen and sugar. 

I. Normal Coloring Matters. Notwithstanding the very 
considerable attention which has been given to this sub- 
ject of late years, there is still some confusion as regards 
the normal coloring matters. Thus, perhaps most recently, 
Hofi^mann and Ultzmann,"^ describing Scherer's method 

•^ Anleitung zur Untersuchung des Harnes, etc. Wien, 187L 



ORGANIC CONSTITUENTS. . 57 

of obtaining his urohsematin, state that it does not con- 
tain iron, while the urohiematin of Harley and the 
urophain of Holler do. Further, they make the uro- 
hwmatin of Harley identical with the uroerythrin of Heller, 
an abnormal coloring matter. 

The fact is, that while it is probable that the true 
coloring matter of the urine has not been precisely deter- 
mined, the urohsematin of Scherer and Harley are iden- 
tical, Scherer* admitting that urohsematin contains iron, 
and approving of the use of the term by Harley for his 
coloring matter. The urophain of Heller is doubtless 
practically the same thing. It will at any rate here be 
so considered. Upon the presence of indican (Heller's 
uroxanthin) in normal urine, all are agreed. So that we 
may safely make two coloring matters in normal urine. 

1. Urohsematin (Harley and Scherer) or urophain 
(Heller). 

2. Indican or the uroxanthin of Heller. 

1. Heller's test for urophain is as follows : About 2 c. c. 
(32.4 minims) of colorless sulphuric acid are poured into 
a small beaker-glass, and upon it in a fine stream from a 
height of about four inches, two parts of urine are allowed 
to fall. The urine mingles itself intimately with the 
sulphuric acid, and in normal urine, of which the specific 

•^ Harley: The Urine aiul its Denuigeinents. Phihulflphia, 
1872, from London Edition, 1871. 



58 PRACTICAL EXAMINATION OF THE URINE. 

gravity is 1020 and the quantity 1500 c. c. in the twenty- 
four hours, produces a deep garnet red coloration. 

If the coloring matter is increased, the coloration is no 
longer garnet red, but is hiach and opaque; whereas, if 
the coloring matter is diminished, the mixture appears 
pale garnet red and transparent. 

Precautions, Unfortunately, other conditions than 
that of increased amount of coloring matter produce the 
increased intensity of the urophain-reaction. Thus 
diabetic urine produces the same dark opacity through 
carbonization of the sugar by the sulphuric acid. In 
like manner, urine containing blood, biliary coloring 
matters, and uroerythrin (an abnormal coloring matter), 
gives the same reaction with sulphuric acid. Before 
relying, therefore, upon this reaction, the above sub- 
stances must be carefully excluded. 

Dr. Harley's test for uroha^matin is as follows : Dilute 
the twenty-four hours' urine with w^ater till it meas- 
ures 60 ounces (1800 c. c), or if the quantity exceeds 
60 ounces, concentrate it to this amount; then add to 
about 2 drachms (7.4 c. c.) of it in a test-tube, half a 
drachm (1.8 c. c.) of pure nitric acid, and allow the mix- 
ture to stand for some minutes. If the quantity of uro- 
h^ematin is normal, the mixture will alter but slightly 
in tint ; whereas, if there be an excess, it will become 
pink, red, crimson or purple according to the amount 
present. Heating the mixture hastens the change in 



ORGANIC CONSTITUENTS. 59 

color, but it is better to do this experiment in the cold, 
and, if necessary, allow plenty of time for the change to 
take place. 

The acid is added to liberate the coloring matter, 
which may be so thoroughly concealed that a pale urine 
often contains a large amount of urohwinatin. 

He gives a second method, also easy of application, of 
determining its excess in cases of destructive diseases of 
the blood. Boil 4 ounces (120 c. c.) of urine, and add 
nitric acid to set the coloring matter free. When cool, 
put the urine in a six-ounce bottle along with an ounce 
of ether. Cork the bottle, thoroughly shake it, and 
place aside for twenty-four hours. At the end of that 
time the ether will be found to be like a red, tremulous 
jelly. Such a case, however, he admits to be a bad one. 
He further says, that ^'in some of the worst cases of 
urohsematuria the urine is neutral, or even alkaline and 
the fons et origo mail is to be looked for in the spinal 
cord." 

Dr. Harley apparently with good reason considers 
that urohsematin arises from the disintegration of tlie red 
blood-corpuscles, and that it iiuctuates, therefore, with 
the rate of destruction of these. 

2. Indican or uroxanthin, the second normal coloring 
matter of the urine is detected by Heller's test as fol- 
lows : 3 or 4 c. c. (48.6 to 64.8 minims^ of puro hydro- 
chloric acid arc poured into a small boaker-ulass, and 



60 PRACTICAL EXAMINATION OF THE URINE. 

into the same while stirring 10 to 20 drops of urine are 
dropped. Under normal conditions indican is j^resent in 
urine in so small quantity that the acid to which the 
urine is added, is colored pale yellowish-red. If indican 
is present in larger quantities, the coloration is violet or 
blue. The more abundant the indican the more rapid 
does the violet or blue discoloration take place, and often 
1-2 drops of urine are sufficient to color, 4 c. c. (64.8 
minims) hydrochloric acid. If, however, the violet color 
does not appear in one or two minutes, the indican is not 
increased, even if after 10 or 15 minutes a dark reddish- 
brown color makes its appearance. If it is desired to 
test urine containing the biliary coloring matters for 
indican, the former must be precipitated by solution of 
acetate (sugar) of lead, and filtered out. 

Indican itself is a colorless substance as is indigo at 
first, separable from urine in the shape of a clear brown 
syrup easily soluble in water, alcohol, and ether. It has 
a bitter taste, and is easily converted under warmth into 
indigo-blue (the uroglaucin of Heller), indigo-red (uro- 
hodin of Heller) and mAigo-glucin, a saccharine sub- 
stance which is said to respond to Trommer's test, but 
not to the fermentation test. 

Dr. Harley believes that all the various colored urine 
pigments are but different grades of oxidation of urohse- 
matin,"^ and thus accounts for the various cases of blue,. 

* Op. citat., p. 110, ad fin. 



ORGANIC CONSTITUENTS. 61 

green, brown and black urines which have been at dif- 
ferent times reported, a most important fact with regard 
to which is that they never exhibit these colors at the 
moment the urine is passed, but acquire them after 
exposure to the air or the action of chemical reagents. 
He believes these changes which occur in urohaematin 
out of the body, are primarily due to its constitution in 
the body having been altered by disease. 

He admits, however, in common with others, that some 
portion of the coloring matter of the urine comes from 
the food, chiefly vegetable food.* 

Clinical Significance of the Increased Urolicematin or 
Urophain Reaction, An increase of the urophain (urohae- 
matin) reaction has been observed under the following 
circumstances (Hoffmann and Ultzmann) : 

1. In concentrated urines. 

2. In fever urines. 

3. In the urine of icterus and in chronic diseases of 
the liver. In the latter, and biliary obstructions, an in- 
crease of the urophain reaction may show itself, even 
when Gmelin's or Heller's test for the coloring matters 
of bile does not respond ; since the products of their 
decomposition may be present when the proper biliary 
coloring matters themselves, bilirubin and bilifuscin, are 
wanting. 



* Op. citat., p. 101, ad tin. 
6 



62 PRACTICAL EXAMIXATIOX OF THE URINE. 

4. Ill diabetic urine containing abundant sugar. 

5. In urine rich in the coloring matters of blood. 

6. A large amount of indican in the urine may also 
give a strong urophain reaction. So marked an increase 
in indican alone very seldom occurs, but it often happens 
that the blue color is recognized at the first moment of 
the test, and gradually passes over into the black ; but 
by dilution with water the blue may again be made to 
appear. 

Clinical Significance of Indican in the Urine, An in- 
crease of indican is found in renal diseases, especially the 
acute, in pyelitis, diseases of the spinal cord and its 
membranes, and especially derangements of the entire 
central and peripheral nervous system, in urina spastica, 
and after coitus. 

It has been found by Neftel in cases of cancer of the 
liver, and its presence in large quantities, in persons 
affected with malignant tumors, he considers pathog- 
nomonic of cancer of the liver ; by Hoppe-Seyler, in a 
case of melanotic cancer of the orbit. Jafle finds indican 
increased in all diseases attended by intestinal obstruc- 
tion, purulent peritonitis, certain forms of diarrhcea, and 
in various diseases where the latter is a symptom. 
Rosenstein found indican increased eleven to twelve 
times in Addison's disease. From these facts it is evident 
that it is difficult to associate it pathognomonically with 
any disease. 



ORGANIC CONSTITUENTS. b3 

II. Abnormal Coloring- Matters. Under abnormal col- 
oring matters are included those which never enter into 
the composition of normal urine, whether found else- 
where in the body or not. 

They include, a, the coloring matters of blood, haemo- 
globin, meth?emogIobin, and hsematin. Hsematin is a 
deoxygenated haemoglobin, into which and a coagulated 
albuminous substance, haemoglobin is converted by the 
action of heat. Metha^moglobin is an intermediate con- 
dition, approaching, however, nearer to hsematin, and 
giving the same absorption band, in the yellow of the 
spectrum between Fraunhofer's lines C and D, but nearer 
to D, while haemoglobin gives two bands in the yellow and 
green between D and E. 6, the uroerythrin of Heller. 
c, vegetable coloring matters, rf, biliary coloring matters. 

a. The coloring matters of the blood, h(emoglobin, and 
methcemoglobin, and hoeinatin. These substances can enter 
the urine either by direct transudation, or arise from the 
dissolution of blood-corpuscles themselves, which have 
entered the urine in different ways. 

The color of the urine is different according as it 
contains more haemoglobin or methaeraoglobin, the former 
being brighter, the latter darker, brownish-red. Hem- 
orrhages from the larger vessels produce more hivmo- 
globin ; capillary hemorrhages, on the other hand, more 
methaemoglobin. Heller pro[)oses to account for tiie dif- 
ference in the fact that in the hemorrhages which take 



64 PRACTICAL EXAMINATION OF THE URINE. 

place from the capillaries in the course of renal diseases, 
the blood is much more intimately and more slowly com- 
mingled with the urine, and therefore longer retained 
with the urine at the normal temperature of the body. 
Temperature, the presence of carbonic acid, and the 
absence of oxygen, may favor the passage of haemoglobin 
to meth^moglobin. 

Detection. 1. By Heller's hsematin test, is as follows: 
Precipitate from urine in a test-tube the earthy phos- 
phates by caustic potash and gentle heat over a flame. 
The earthy phosphates carry with them as they sink the 
blood-coloring matters, and appear therefore not white 
as in normal urine, but blood-red. When the quantity 
of coloring matter in urine is very small the earthy 
phosphates appear dichroic. If the urine is already 
alkaline, and no precipitate of earthy phosphate appears 
on the addition of liquor potas.sse and heat, a precipitate 
can be artificially produced by the addition of one or 
two drops of the magnesian fluid, which, with the appli- 
cation of heat, carries down the coloring matters. 

To Prepare Hcmiin Crystals. If the precipitated earthy 
phosphates are filtered out and placed on an object- 
glass, and carefully warmed until the phosphates are 
completely dry, Teichmann's hsemin crystals can be 
produced therefrom. For this purpose a minute granule 
of common salt is carried on the j)oint of a knife to the 
dried h?ematin and earthy phosphate, and gently mixed 






OUGANIC CONSTITUENTS. 65 

with it. Any excess of salt is then removed, the mixture 
is covered with a thin glass cover, a hair interposed, and 
a drop or two of glacial acetic acid allowed to pass 
under. The slide is then carefully warmed until bub- 
bles begin to make their appearance. After cooling, 
hsemin crystals can be seen by aid of the microscope, 
which, though often very small and incompletely crys- 
tallized, are easily recognizable by sufficient amplifica- 
tion. 

Precautions. Care must, however, be taken to apply 
only a gentle heat in precipitating the earthy phosphate 
with caustic potash solution, and to filter quickly, else 
the hsematin may be decomposed. 

It sometimes happens also that vesicles develop under 
the thin glass cover, after the addition of acetic acid, 
even before heat has been applied. These are carbonic 
acid which has developed out of the earthy phosphates. 
These should be allowed to pass away, and then the slide 
warmed until the formation of vesicles, that is, to the 
boiling-point of acetic acid. 

2. The blood coloring matters in urine may also be 
demonstrated by coagulating the albumen by boiling, fil- 
tering off the brown coagulum, drying and treating it with 
alcohol containing sulphuric acid. This alcoholic solution 
contains the luematin, and if the alcohol be ovaporatiHl, 
lueniin crystals can be obtained from the residue in the 
manner above described. 



66 PRACTICAL EXAMINATION OF THE URINE. 

Occurrence. Hsematinuria, that is the direct passage 
of the coloring matters alone from the blood into the 
urine, occurs in certain general diseases, as scurvy, pur- 
pura, scarlatina, etc. Hcematuric or bloody urine occurs, 
of course, from a variety of causes which require no 
special mention. These coloring matters of the bloody when 
present in urine, are always accompanied by albumen. 

b. Uroerythrin. Heller ascribes the well-known dark 
reddish-yelloiv or " high" color of all fever urines to the 
presence of a substance which he- calls uroerythrin, as well 
as to an increase of the normal coloring matters. Except 
that it contains iron, little else that is certain is known 
with regard to uroerythrin. To it he ascribes the reddish 
color which so often characterizes the deposits of urates 
known as '^lateritious;" if the supernatant urine in such 
cases be treated with solution of neutral acetate of lead, 
the precipitate presents a similar "rosy red" or ''flesh 
color," which he attributes to the same substance. It is 
doubtless a modified hsematin, being found especially in 
diseases where there is evident blood dyscrasia, as in low 
fevers, septic conditions, etc. It so far at least corre- 
sponds w^ith the urohiematin of Harley that it is a meas- 
ure of the destruction of the blood-corj)uscles, though it 
will be remembered that the urohcematin of Harley is 
looked upon as a normal constituent of urine which may 
be abnormally increased, while uroerythrin, although a 



ORGANIC CONSTITUENTS. fj7 

modified ha3matin, is still not considered identical by its 
discoverer. 

Detection, Uroerythrin is known to be present })y its 
pink coloration of the " lateritious " sediment, or by its 
precipitation by solution of neutral acetate of lead.* Too 
much lead solution must not be added lest the precipitate 
be too abundant, and therefore the coloring matter be 
rendered less distinct by its being disseminated over a 
large amount of deposit. If the urine contain hsematin 
or the coloring matter of blood, it must first be removed. 

Precautions, 1. The froth of a urine highly charged with 
uroerythrin may appear yellow, as that of urine contain- 
ing biliary coloring matter, but the precipitate of the 
latter by acetate of lead is also yellow and not pink as 
with uroerythrin. 

2. The earthy phosphates which are precipitated on 
heating the urine with caustic potash, are dirty gray 
when the urine contains uroerythrin, w^hile in urine con- 
taining hsematin they are "blood red'' or dichroic. The 
absence of albumen from the urine, the gray coloration 
of the earthy phosphates, and the red precipitate with 
solutions of lead, serve as points in the differential diag- 
nosis between uroerythrin and the coloring matter of the 
blood. 

Clinical Significance. Uroerytlirin is found in the urine 
in all febrile affections, even the sliglitest catarrh ; espe- 
cially in pyaMnia, diseases of the liver, and load colic. 



68 PRACTICAL EXAMINATION OF THE URINE. 

All urine, according to Heller, which contains uroery- 
thrin must be abnormal. 

c. Vegetable Coloring Matters. The coloring matter of 
plants, especially chrysophanic acid found in rhubarb 
and senna leaves, contributes to alkaline urine a reddish- 
yellow to a deep red color. It can be recognized by the 
fact that the red alkaline urine by the addition of an 
acid becomes yellow, and by the addition of an excess of 
ammonia again takes on the red color. 

Precautions. Such precipitation by heat and potash 
solution might possibly be taken for blood coloring mat- 
ters. But the absence of albumen in the urine, the pro- 
duction of the red color by addition of an excess of 
ammonia, and its paling on the further addition of an 
excess of acid, serve to distinguish this vegetable coloring 
matter from blood coloring matter and uroerythrin. 

Numerous other vegetable matters color the urine, 
among which santonin is conspicuous for the bright yellow 
color it produces in acid urine, while the staining of 
linen by it closely resembles that of biliary coloring 
matter. 

Dr. W. G. Smith (Dub. Quar. Jr. Med. Sci., Nov. 1870) 
has investigated the subject, and found that the addition 
of an alkali causes the development of a fine red cherry 
or crimson color, according to the amount of santonin 
present ; but it will be observed that this reaction is that 



ORGANIC CONSTITUENTS. G9 

of the vegetable coloring matters generally, as above 
described. 

Madder, gamboge, rhubarb, logwood, carrots, whortle- 
berries, etc., give to urine more or less of their peculiar 
color. 

d. Biliary Coloring Matters. — The Detection of Bile in 
the Urine. When bile is abundantly present in urine, 
the yellow color of the fluid, and especially of the froth 
or foam produced by shaking, is sufficient to excite sus- 
picion. Further, if a piece of filtering-paper or a piece 
of linen be moistened with such urine, it retains a per- 
manent yellow color on drying. 

The only positive proof of the presence of the coloring 
matters of bile in the urine is found in Gmelin's or 
Heller's test for the unaltered coloring matters. 

Gmelin^s nitrous acid test is performed in two ways : 

First. A quantity of urine is placed in a test-tube, and 
a small quantity of fuming nitric acid (nitrous acid of 
commerce) is allowed to pass carefully dow^n the sides of 
the test-tube to underlie the urine as described in Heller's 
test for albumen. If biliary coloring matters are present, 
at the point of union between the urine and the acid will 
very soon be seen a set of colors which, if typical, should 
be green, blue, violet-red, and yellow, or yellowish-groon 
again in the order named from above downward. Ot'ion, 
however, one or more colors are wanting. Tiio groon is 
most constant, and the first green indispoisablc to prove 



70 PRACTICAL EXAMINATION OF THE UEINE. 

the presence of bile, but violet shading into red and yel- 
low is also very constantly seen. 

A modification of this consists in mixing with urine in 
a test-tube weak nitric acid, and then passing under it 
as above pure sulphuric acid. The same set of colors 
occurs. 

Second. Equally satisfactory is the test if a few drops 
of the urine are placed upon a porcelain plate, ''and as 
much of the fuming acid placed adjacent and allowed 
gradually to approach the urine. The same play of colors 
occurs. 

Heller's test. Pour into a small beaker-glass about 
6 c. c. (1.6 f5) of pure hydrochloric acid, and add to it, 
drop by drop, just sufficient urine to clearly color it. The 
two are mixed and ^^ underlaid" as before with pure 
nitric acid, and at the point of contact between the mix- 
ture and the colorless nitric acid, a handsome play of 
colors appears. If the "underlaid" nitric acid is now 
stirred with a glass rod, the set of colors which were 
superimposed upon one another now appear alongside 
of each other in the entire mixture, and should be studied 
by transmitted light. Heller further says, if the hydro- 
chloric acid on addition of the biliary urine is colored 
reddish-yelloiv, the coloring matter is bilirubin; on the 
other hand, if it is colored green it is biliverdin. 

If the amount of coloring matter is very small, a large 
quantity of urine should be shaken with chloroform ; the 



ORGANIC CONSTITUENTS. 71 

chloroform allowed to separate at the bottom of the vessel 
ill large drops. The yellow-colored chloroform is then 
removed by means of a pipette, washed with distilled 
water, and poured into a beaker-glass containing hydro- 
chloric acid. The yellow drops of chloroform sink to the 
bottom. If now while diligently shaking the glass, nitric 
acid is added, the changes of color can be distinctly 
observed in the chloroform. In consequence of the slower 
action of the acid upon the coloring matters dissolved in 
the urine and the consequent slower transition of colors, 
this method is peculiarly adapted for demonstration. 

Precautions. 1. With neither test should too dark- 
hued a urine be employed, but it should first be diluted 
with water. 

2. Should albumen be present, the opaque zone at the 
point of contact between the urine and acid imbibing the 
coloring matters will exhibit a green coloration, and so 
in no way interfere with the test. 

3. Urine rich in indican may however deceive, forming 
at the point of contact a blue layer of indigo, which, 
along with the yellow urine in reflected light, may appear 
green. In these doubtful cases the chloroform modifica- 
tion of the test should be used, or the urine may be 
precipitated with solution of acetate of lead, and the 
filtrate examined for indican. 

4. The earthy phosphates, precipitated iVom biliary 



72 PEACTICAL EXAMINATION^ OF THE UEINE. 

urine by liquor potass^e aud heat, exhibit a brown 
coloration. 

Test for Decomjjosed Biliary Coloring Matters. Should 
the urine contain only altered biliary coloring matters 
which respond neither to Gmelin's or Heller's test, it may 
be tried as follows : 

A piece of white linen or filtering-paper is immersed 
in the suspected urine, and allowed to dry, when it will 
appear colored brown. A further confirmation that the 
decomposed coloring matters are present will be found in 
a low specific gravity and a dark urophain reaction. If, 
moreover, the urine be treated with liquor potassse and 
heat, to precipitate the earthy phosphates, it becomes 
darker than before and the phosphates are precipitated 
brown. 

X. The Biliary Acids. From a perusal of almost 
all of the existing text-books on physiology, and even of 
numerous manuals on the examination of urine, the 
student is led to suppose that the detection of bile acids, 
if present in urine, by means of what is called Petten- 
kofer's test, is one of the easiest possible. On the other 
hand nothing is farther from the truth, and the fact is 
that such detection by the direct ajjj^^Ucation of the elements 
of Pettenkofer^ s test in urine, or any other animal fluid, is 
practically impossible, even if the bile acids are present in 
condderable amount. Nor have any of the modifications 
of Pettenkofer's test, recently announced as clinically 



ORGANIC CONSTITUENTS. 73 

available, proved such in my hands, even where the ele- 
ments of bile have been added to the urine, except where 
inspissated ox-bile has been used. The results of a com- 
plete investigation of this subject in its practical bear- 
ings will be found in a clinical lecture by the writer, in 
the Philadelphia Medical Times, for July 5th, 1873, " On a 
case of Jaundice, with remarks on the availability of 
Pettenkofer's test," to which the student is referred. In 
these experiments the simplest method of obtaining the 
biliary acids was found to be as follows: Six or eight 
ounces (180-240 c. c.) of the suspected urine are evapo- 
rated to dryness over a water-bath. The residue thus 
obtained is treated with an excess of absolute alcohol, 
filtered, and the filtrate treated w^ith an excess of ether 
(12 to 24 times its bulk), by which the bile-acids, if 
present, are precipitated. These are then removed by 
filtration and redissolved in distilled water. The solu- 
tion is then decolorized by passing through animal char- 
coal the resulting colorless fluid, tried by Pettenkofer's 
test as follows: A single drop of a 20 per cent, solution of 
cane-sugar (simple syrup of the Pharmacopana is many 
times too strong) is then added to a drachm or two 
(3.7-7.4 c. c.) in a test-tube or porcelain capsule. Sul- 
phuric acid is then added drop by drop, while the tost-tubo 
is kept in a vessel of cold water, to prevent too great a 
rise in temperature, which should not exceed 50^^-70 ' C 
(122^-158° R). As the quantity added approaelies a bulk 



74 PRACTICAL EXAMINATION OF THE URINE. 

equal to that of the fluid tested, a beautiful cherry red, or 
purple-violet color should make its appearauce. So soon 
as a yellow color makes its appearance, then the sul- 
phuric acid is acting on the sugar, and the cherry red can 
no longer be looked for. This carbonizing of the sugar 
is obviated by keeping the temperature down to the de- 
gree mentioned. 

Even this method involves more time than is often 
available to the active practitioner, but there is none 
more simple, and there is really rarely any necessity for 
any other than the color test, for the presence of the 
biliary acids, although undoubtedly occurring, is very 
rare, and the circumstances under which they occur are 
illy determined. It is not true, as was once supposed, 
that they are always present in the urine in cases of oh- 
struction, and consequent reahsorption of bile, and absent 
in cases of sujypression, else would the determination of 
their presence be of real value in diagnosis. The only 
circumstances under which they are undoubtedly present 
in the urine are as rapidly destructive diseases of the 
liver, as acute yellow atrophy, and phosphorus pois- 
oning. 

XI. Leucin and Tyrosin. Leucin and ty rosin, 
products of a retrograde metamorphosis of nitrogenous 
substances, are found physiologically only in certain fetid 
secretions, as those of the axilla and between the toes, 
but can be produced by chemical means from some 



OKGANIC CONSTITUENTS. 75 

glands, as the liver, pancreas, and spleen, where they 
also occur in certain pathological states. They are found 
in the urine chiefly, in rapidly destructive diseases of the 
liver, as acute yellow atrophy, or phosphorus poisoning, 
but occasionally also in typhus and small-pox. They 
always accompany a large amount of biliary coloring 
matter, and the presence of albumen. When at all 
abundant, as they generally are in acute yellow atrophy, 
they are deposited from the urine and are found in the 
sediment, the former in the shape of centrically marked 
spheres, arranged in warty masses, or druses, the latter 
in needles. (Fig. 18.) 

Schultzen has shown* that in animals poisoned by 
phosphorus, "urea disappears from the urine, and is 
replaced by leucin and tyrosin, which in the healthy 
organism are converted into urea.'^ A similar substitu- 
tion takes place, in cases of acute atrophy of the liver, 
the retained urea accounting for the convulsive attacks 
which usually precede death in these cases. 

Detection. If the crystals, to be more fully described 
in treating of sediments, do not present themselves in the 
spontaneous deposit of such cases, the evaporation o'i a 
small quantity of the urine will generally promptly dis- 
play them. 

■^ Boston Medical and Surgical Journal, July 28, 1874, from 
Zoitschrift fiir Biologic, viii, ll24, and Berliner Wochcnschrift, 
1872, p. 417. 



76 PRACTICAL EXAMINATION OF THE URINE. 

If they are not sufficiently abundant to be thus de- 
monstrated, the method of Frerichs must be pursued to 
separate them. A large amount of urine is precipitated 
with basic acetate of lead, filtered, the excess of lead 
removed from the filtrate by sulphuretted hydrogen, 
and the clear fluid evaporated over a water-bath to a 
small volume. In twenty-four hours tyrosin needles will 
be found to have crystallized out, but leucin spheres 
will not appear until later, on account of their greater 
solubility.* 

XII. Urea. 0^211^0. The chief organic constituent 
of the urine and the index of nitrogenous excretion, the 
quantity of urea fluctuates with changes in the quantity 
and composition of ingesta, and with the rapidity of 
tissue metamorphosis in health and disease. A range of 
from 20 to 40 grammes (308.6 to 617.2 grains) must at 
least be admited in adults. 

Detection and Estimation, The odor of urine highly 
charged with urea, may be said to be characteristic, but 
certain evidence of its presence can only be obtained by 
treating the solution suspected to contain it with nitric 
or oxalic acid. Though crystallizing itself in glistening 
needles, it is too soluble to permit of easy detection by 

^ Leucin and tyrosin are more fully treated by the writer in 
the American Journal of the Medical Sciences for January, 
1872. The above is believed to be sufficient for practical pur- 
poses. 



ORGANIC CONSTITUENTS. 



77 



its own form. If it be desired to detect its presence in a 
suspected fluid, a drop or two is placed upon a glass 
slide, a drop of nitric acid added, the slide carefully 
warmed over a spirit-lamp, and placed aside to crystal- 
lize. If urea is present, the microscope will reveal 
singly or in plates six-sided, and quadrilateral crystals 
of nitrate of urea. Fig. 8. The crystals have acute 

Fig. 8. (After Beale.) 




Crystals of nitrate of urea. 



angles measuring about 82°, and are so characteristic as 
to be easily recognizable. 

In the plates the crystals often overlap each other 
like the shingles of a roof Solution of oxalic acid pro- 
duces similar but less regular ci'vstals of oxahite oi^ 
urea. 



78 PRACTICAL EXAMINATION OF THE URINE. 

In ordinary healthy urine, this crystallization does not 
take place unless the urine is concentrated by evapora- 
tion. But in some urines highly charged with urea, it is 
simply necessary to add nitric acid to produce the crys- 
tals, and thus is arrived at a rough quantitative estima- 
tion for urea. 

As urea is by far the most abundant solid constit- 
uent of the urine, it follows that the specific gravity 
may become a means of approximately estimating its 
amount, especially Avhen there is no sugar present, if 
the quantity of albumen is small, and that of the 
chlorides is normal. A specimen of urine, containing 
neither albumen or sugar, a normal proportion of 
chlorides, and a specific gravity of 1020-4 to a quantity 
of 1500 c. c. (50 oz.) in twenty-four hours, may be taken 
as a standard normal specimen containing 2 per cent, to 
2J per cent, of urea. These conditions being observed, 
a higher specific gravity would indicate an increased 
proportion of urea, and a lower a diminished proportion. 
Under these circumstances, a specific gravity of 1014 
indicates about 1 per cent, of urea, and of 1028 to 1030 
about 3 per cent. 

But the chlorides fluctuate markedly in some diseases, 
and by far the largest proportion of urines, in which a 
knowledge of the amount of urea is important, contain 
albumen. Next to urea, supposing albumen and sugar 
absent, the chlorides most affect the specific gravity, 



ORGANIC CONSTITUENTS. 79 

being separated to the amount of 10 to 16 grammes (154 
to 247 grains), or I to 1 per cent, in the twenty-four 
hours. If these are totally absent, as tliey often are in 
pneumonia and other febrile diseases, characterized by 
an increase in the elimination of urea, then must a 
specific gravity of 1020 indicate more than 2^ per cent, 
of urea, or if the percentage of chloride replaced by 
urea be added, 3^ per cent. This is supposing, of course, 
as is the case, that the remaining constituents, uric acid, 
creatinin, phosphates, sulphates, etc., have little influence 
on the specific gravity. 

If albumen is present in small quantity, not exceeding 
j^Q per cent., as determined by the approximative method 
given for albumen, it has little effect, and it can be 
thrown out of the question. If, however, the albumen 
be more abundant, 1 to 2 per cent., it must first be re- 
moved by coagulation and filtration, and the approxi- 
mate estimation be made from the specific gravity of the 
filtrate after cooling. Care must of course be taken to 
wash the coagulum by further addition of water until 
the quantity of fluid originally operated with is restored. 
After such removal of albumen, if not before it, the spe- 
cific gravity will generally be found diminished, showing 
what volumetric analysis has determined more precisely, 
that in chronic albuminuria, at least, the quantity of 
urea is generally diminished. 

Where sugar is present the percontago of uroa is also 



80 PRACTICAL EXAMIXATION OF THE URINE. 

generally less, though with increased specific gravity, 
while the large total quantity of urine in the twenty-four 
hours may show an increase in the total urea for the 
day. There is no way of allowing here for the increased 
specific gravity due to the presence of sugar, and the 
only way to arrive at a knowledge of the amount of urea 
is by volumetric analysis. 

Volumetric Analysis. Under any circumstances, when 
an accurate estimation of urea is required, we must have 
recourse to volumetric analysis. Several methods of. 
volumetric analysis for urea have been suggested, of 
which that of Liebig, with the nitrate of mercury solu- 
tion, seems most to combine accuracy and convenience. 
Davy's method, with the sodium hypochlorite and pure 
mercury, is, in some respects, more simple, but it is also 
more liable to error, and really takes more time for its 
completion, while Liebig's process is carried out with 
surprising celerity, after even a little experience, not 
more than fifteen minutes being required to complete it 
if the solutions are at hand. 

Liebig's process is based upon the fact that urea pro- 
duces an insoluble precipitate with mercuric nitrate. 

The following test-solutions are required : 

1. The Baryta solution, consisting of one volume 
of cold saturated solution of barium nitrate, with two 
volumes of cold saturated solution of caustic baryta 
(barium hydrate). 



ORGANIC CONSTITUENTS. 81 

2. A saturated solution of sodium carbonate, or some 
filtering-paper impregnated with the latter. 

3. A standard solution of mercwic nitrate of such 
strength that 1 c. c. is precisely equivalent to .010 
gramme, or 10 milligrammes of urea (.15 grain). 

To Prepare the standard Solution of MercurHc Nitrate. 
1. Dissolve about 75 grammes (1157.25 grs.) of pure mer- 
cury in pure boiling nitric acid. The acid fluid is concen- 
trated by evaporating over a water-bath to a syrupy con- 
sistence, and then diluted to the volume of a litre (2.1 
pints) of distilled water. Unless a great excess of acid 
remains after evaporation, a white precipitate of basic 
nitrate of mercury will fall, which must be removed by 
filtration ; previously, however, a few drops of nitric acid 
should be added which will dissolve the greater part of the 
precipitate without making the solution too acid. The 
solution requires to be graduated by 

2. The standard Solution of Urea. Two grammes (30.86 
grs.) of pure urea should now be dissolved in 100 c. c. (27 
f^:^) of distilled water, of which 10 c. c. (2.7 f^) will then 
contain 0.2 gramme (3.08 grs.) or 200 milligrammes. 

Ten c. c. of this standard solution containing 200 milli- 
grammes of urea are now placed in a beaker-glass. A 
burette is then filled to with the solution of mercuric 
nitrate (taking care that the lower edge of the meniscus 
which forms the upper surface of the liquid corresponds 
with the arrow on the burette), which is then allowtul to 
drop into the beaker, where it will quit'kly I'orni a dense 
precipitate. AV^hen tlu* precipitation seems nearly I'om- 



82 PRACTICAL EXAMINATION OF THE URINE. 

plete, a drop of the fluid containing it is allowed to fall on 
a drop of the solution of sodium carbonate on a piece of 
glass on a dark ground, or on a piece of filtering-paper 
impregnated with the sodic solution. If the urea is not 
completely precipitated, no change of color takes place. 
The cautious addition of the mercuric nitrate is continued, 
and the process of testing with the NagCO.^, until finally a 
yellow color appears. This proves that the mercuric nitrate 
has been added in excess, — consumed all the urea in com- 
bination and left some mercuric nitrate to react with the 
sodic carbonate, which it does b}^ forming sodic nitrate and 
the yellow oxide of mercury. 

The number of cubic centimetres consumed in reaching 
the point as read ofi:'' on the burette, indicates the quantity 
of mercuric nitrate which is equivalent to 200 milligrammes 
of urea. Whence it is easy to calculate how much further 
the solution should be diluted to make 10 c. c. = 100 milli- 
grammes of urea or 1 c. c. =: .010 gramme (10 milli- 
grammes). 

Thus suppose that 17.3 c. c. (4.67 f^) of the solution of 
mercuric nitrate are required to precipitate the .200 gramme 
of urea; then, if 2.7 c. c. (.73 f^) water are added to this 
quantity, we will have 20 c. c. = .200 gramme or 10 c. c. == 
.100 gramme or 1 c. c. ^ .010 gramme or 10 milligrammes 
as required. 

It is scarcely necessary to say that the quantity (75 gms.) 
of mercury originally taken is selected, because it is known 
that that amount treated as above and diluted to a litre 
will give very nearl}^ the proportion required. 

Process. Take 40 c. c. (10.8 f 5) urine and 20 c. c. (5.4 



ORGANIC CONSTITUENTS. 



83 



f 5) of the baryta solution, and throw them into a beaker- 
glass. By this means the phosphates, sulphates, and 
carbonates are precipitated. They are removed by filtra- 
tion through a dry filter, and if the filtrate happen not 



Fig. 9. (After Ilarloy.) 




to be quite clear, it may be passed through a second time. 
While this is taking place, the burette is filled to with 
the mercuric nitrate solution, and 15 c. c. (2.7 f5) of the 
filtrate from the mixed baryta fluid and urine, contain- 
ing of course 10 c. c. (2.7 f5) of pure urine, are measured 
off into a small beaker-glass. Into this the nicrrurie 
nitrate solution is allowed to fall from tlie buivtio, tir>t. 



84 PRACTICAL EXAMINATION OF THE URINE. 

to a number of cubic centimetres approaching the last 
two figures of the specific gravity (that is, if the specific 
gravity is 1017, drop 15 c. c.) before testing with the soda 
solution or soda paper. If no yellow coloration appears, 
then proceed cautiously, a cubic centimetre or two at a 
time, testing with the Na2C03 until the yellow coloration 
is struck. When that point is reached, read oflf the num- 
ber of cubic centimetres employed. The number of cubic 
centimetres of mercury solution thus used, minus 2 and 
multiplied by .010 gramme, gives the amount of urea in 
fractions of a gramme contained in 10 c. c. (2.7 f5) of the 
urine, when the latter is of average composition, that is 
when it contains nothing abnormal, and the amount of 
chlorides is about the average. 

The two cubic centimetres are first subtracted because it 
takes about this quantity to decompose the chlorides which 
first form a soluble precipitate with the mercuric nitrate, 
and until they are all thrown down, the combination with 
the urea does not begin. Hence this amount must first be 
subtracted. 

If, however, the chlorides are not of average amount 
but diminished or increased, and we wish to be accurate, 
we must first estimate the amount of chlorides calculated 
as NaCl in 10 c. c. of the urine, by the process to be 
explained under chlorides, and the whole of the chlorides 
must be removed from a fresh quantity of urine by a stand- 
ard solution of silver nitrate. For this purpose a solution 



ORGANIC CONSTITUENTS. 85 

of nitrate of silver is required of strength corresponding to 
that of the mercuric nitrate solution, i. e , such that 1 c. c. 
will precipitate 10 milligrammes sodium chloride. 11.001 
grammes (179.00 grs.) of fused nitrate of silver, dissolved 
in distilled water, and diluted to a litre, will be such a fluid. 

Take 30 c. c. (8.1 f^;) of the filtrate from the mixture of 
baryta fluid and urine, add a drop of nitric acid, and drop 
in from the burette twice as many cubic centimetres of the 
nitrate of silver solution (supposing 15 c. c. to have been 
the quantity there operated with) as cubic centimetres of 
the nitrate of mercury solution used in the chlorine estima- 
iiou. A precipitate of the chlorides will take place, which 
should be removed by filtration, and the filtrate may be 
now estimated for urea. It is only necessary always to bear 
in mind the exact amount of urine operated with after 
adding the nitrate of silver solution to a mixture of baryta 
solution and urine, of which only two-thirds are urine. 
Thus if 10 c. c. of the silver solution are added to 30 c. c. 
of the filtered mixture of urine and baryta fluid, of the 
resulting 40 c. c, 20 would be urine minus the chlorine, 
or out of 20 c. c. 10 would be urine minus the chlorine. 

If the case be one of inflammation, as pneumonia, where 
there is a total or almost total absence of chlorides, they 
may be thrown out of the question altogether. 

Further correction. If the number of cubic centimetres 
of mercury solution added to 15 c. c. of the mixture of 
urine and baryta fluid exceeds 30, the process must be re- 
peated, adding to 15 c. c of the liquid as many cubic centi- 
metres of distilled water as equals the dilference between 
30 and the number used in the first operation. 
8 



86 PRACTICAL EXAMINATION OF THE URINE. 

XIII. Uric Acid — C^oH^N^Og. When uric acid is 
spoken of as a constituent of urine, it is never to its free 
state that allusion is made, but to its combinations 
chiefly with potash, soda and ammonia, but also with 
lime and magnesia, usually known as mixed urates. 
Uric acid itself is so extremely insoluble (one part 
requiring 14,000 of cold and 1800 of hot water to dis- 
solve it) that it is immediately precipitated on being 
freed of its bases. In quantity it is found ranging .4 to 
.8 gramme (6.17 to 12.34 grs.) in the twenty-four hours, 
in health varying pari passu with urea of which it is a 
stage short in oxidation. 

Detection by the Microscope. Its presence as such is 
recognized by the microscopic characters of its crystals, 
which in their typical form may be said to be '' lozenge- 
shaped," or as best described by the Germans ^^whet 
stone-shaped." They are, moreover, always colored 
yellowish-red or red, being with their salts the only 
urinary deposits thus stained, so that when a sediment is 
seen of which the elements are thus colored, it may, with- 
out hesitation, be put down as composed of uric acid or 
its combinations. More will be said of these crystals in 
treating of sediments, where their discussion more prop- 
erly belongs. 

The Murexid test. The murexid test for uric acid and 
its combinations is one of extreme beauty. A small 
portion of sediment, or the residue after evaporation, is 



ORGANIC CONSTITUENTS. 87 

placed on a porcelain plate or piece of platinum, a drop or 
two of nitric acid added to dissolve it, and then carefully 
evaporated over a spirit-lamp flame. When dry, a drop 
or two of liquor ammouia is added, when there promptly 
appears a beautiful purple color, which will gradually 
suffuse itself as the ammonia spreads. The murexid 
reaction is believed to depend upon the origin of alloxan, 
alloxantin, and ammonia, under the action of the hot 
nitric acid. This reaction is also said to occur with 
tyrosin, hypoxanthin, and xauthoglobulin, and Schiff 
accordingly recommends the 

Carbonate of Silver Test for Urea, This is very deli- 
cate, and is most conveniently applied as recommended 
by Harley. Dissolve a little uric acid in a solution of 
sodium or potassium carbonate, place a drop or two of 
the solution on paper, and add a solution of nitrate 
of silver. A distinct gray stain promptly occurring 
indicates the presence of uric acid. 

Neither of the tests, however, discriminates between 
uric acid and urates. The microscope alone can do this. 

Quantitative Estimation of Uric Acid. To 200 c. c. 
(54 f5) add 20 c. c. (5.4 f3) of hydrochloric or nitric 
acid, and set aside in a cool place, as a cellar, for twenty- 
four hours. At the end of that time the uric acid crys- 
tals, highly colored, will be found adln^-ing to the sides 
and at the bottom of the beaker. Collect the uric acid 
on a weighed filter, wash thoroughly with distilled 
water. Dry the filter and uric acid at a temperature of 



88 PRACTICAL EXAMIXATIOX OF THE URINE. 

100^ C. (212° F.), weigh, and the weight of the two, 
minus the weight of the filter, will be the weight of the 
uric acid in 200 c. c, except the small portion retained 
in the acid and washings. Xeubauer advises to add to 
the result 0.0038 grammes uric acid for every 100 c. c. 
of these fluids. 

XIV. Urates. It has already been said that in 
health, practically all the uric acid of the urine is held 
in combination with potash, ammonia, soda, lime, and 
magnesia, of which those with potash and ammonia 
are most abundant according to Bence Jones. These 
are very soluble compounds at the temperature of the 
body, but are precipitated in amorphous granules when 
the temperature of the urine is lowered, as in winter 
weather. 

Their physiological and pathological significance de- 
pends altogether upon the uric acid they contain, but 
there are some points of reaction with which the student 
should be quite familiar. These grow out of the fact 
that uric acid is a bibasic acid, forming neutral and acid 
salts, and that the acid salts are much less soluble than 
the neutral, requiring 124 parts of boiling and 1120 parts 
of cold water for their solution. They form, therefore, 
the bulk of urate deposits, while urates, which remain 
in solution after such reduction of temperature as con- 
stantly takes place in an apartment, must be, if not 
neutral, at least less acid than those which form the 
sediment. And a solution remaining^ for some time 



ORGANIC CONSTITUENTS. 89 

clear under such circumstances, must contain urates of 
soda, etc., with a large proportion of the alkaline base. 

The practical application of this fact is seen in this, 
that when an acid is added to such solution of neutral 
urate, by seizing upon a portion of the base, it leaves an 
acid urate of soda, which, in consequence of its relative 
insolubility, is promptly precipitated in a finely granular 
form, producing a decided opacity. Now, this is pre- 
cisely what often happens in the nitric acid test for 
albumen. The urine is highly charged with neutral 
urates which are held in solution. Nitric acid is added, 
and down goes a precipitate, not crystalline, but amor- 
phous, which is composed of acid urate of soda. And 
if Heller's method is followed, an opaque zone is 
formed at the point of contact between the acid and 
urine, which may be mistaken for albumen, but which, 
besides presenting certain visual characters of its own, 
which have been described, p. 38, is readily soluble by 
heat. If urine presenting this reaction with acid be 
allowed to stand for some time, the milky opacity grad- 
ually passes away, and is substituted by a very small 
crystalline sediment of uric acid. By longer action oi 
the acid, the remainder of the base is entirely withdrawn, 
leaving the free acid, which is deposited in crystals. 

The remaining organic constituents oi the uriiio, 
creatiniu, creatin, xanthin, hippuric acid, oxalic acid. 



90 PRACTICAL EXAMINATION OF THE URINE. 

lactic acid, and phenylic acid, having little practical sig- 
nificance as such, require only to be mentioned in this 
connection. 

Mucus and the crystalline combination of oxalic acid 
with lime will be further considered in treating of sedi- 
ments. 

Hippuric acid is interesting in forming one of the 
most striking connecting links between the urine of 
carnivora, omnivora, and herbivora, replacing in the 
last the uric acid of the first, while in man, who con- 
sumes a mixed diet, we have both uric acid and hippuric, 
that is, an intermediate state. But while hippuric acid 
is increased in man by a vegetable diet, yet it is not 
wholly absent with animal food. It is increased in 
diabetes, where also it almost replaces uric acid. If 10 
grains benzoic acid be taken in the evening, the next 
morning crystals of hippuric acid will usually be found 
in the urine. The typical form of these is a four-sided 
prism, with two or four bevelled surfaces at its ends, 
but from this there are deviations. In the twenty-four 
hours' urine of man, .5 to 1 gramme (7.7 to 15.4 grs.) 
are separated. 

Inorganic Constituents. 

XV. The Chlorides. The chlorides found in the 
urine are chiefly those of sodium, with a small propor- 
tion of chloride of potassium and ammonium. 



INOIiGANIC CONSTITUENTS. Ijl 

In health the chlorides are almost an exact measure 
of the same substances taken in with the food, and 
amount to 10-16 grammes (154.3 to 246.8 grs.) 

Detection and approximate Estimation. If a drop of 
urine be slowly evaporated on a glass slide, characteristic 
octahedral crystals and rhombic plates of a combination 
of urea and chlorine make their appearance, and may 
be examined by the microscope. But more available 
for detection and approximate estimation is 

The Nitrate of Silver Test, Nitrate of silver in solu- 
tion throws down both the phosphates and chlorides 
from the urine. But if a few drops of nitric acid be 
first added, the phosphates will be held in solution, and 
only the chlorides will fall as opaque white chloride of 
silver. 

From normal urine containing ^ to 1 per cent, of 
chlorides, they are precipitated by a single drop of a 
solution of nitrate of silver, 1 part to 8, in cheesy lumps, 
which do not further divide themselves, or make the 
urine more milky by moving the glass about. //', Jwiv- 
ever, the chlorides are diminished to y\) per cent, or less, 
the addition of a single drop of the silver solution no 
longer produces the white cheesy lumps, but a simple 
cloudiness, and the entire fluid appears equally milky. 
If, finally, there should be no precipitate whatever, thou 
the chlorides are totally absent. 

The presence of albumen in moderate amount does 



92 PRACTICAL EXAMINATION OF THE UKINE. 

not interfere with the test, but if abundant, it must be 
removed. 

Clinical Significance. The chlorides are diminished 
ill all febrile conditions, whether of local or general 
origin. Especially is this the case where there are any 
exudations, solid or fluid, by which they seem to be 
eliminated. In acute pneumonia, where they are often 
totally absent from the urine, they appear abundantly 
in the saliva. In this affection, and indeed, in all 
acute diseases, their disappearance from the urine in- 
dicates an increment in the disease, and their reap- 
pearance an improvement. In pneumonia a decline in 
the disease may often be detected through their return 
before physical or any other signs point to improvement. 
Hence a daily trial of the urine for them becomes im- 
portant. 

Volumetric Process. The volumetric process employed 
may be that of Liebig with solution of mercuric nitrate, 
or that with silver nitrate. 

Liebig's process depends upon the fact that chlorine 
forms with urea a soluble compound, and urea an in- 
soluble precipitate; and the precipitate with urea does 
not appear until all of the chlorides are consumed in 
combination. The solution of nitrate of mercury is 
less concentrated than that employed for the urea, in 
order that the chlorides may not be thrown down too 
rapidly for accurate observation. 



INOKGANIC CONSTITUENTS. 93 

The solutions required are : 

1. A solution of sodium chloride, 20 grammes ("308.6 
grs.) of the pure salt, which should be fused before being 
weighed, in a litre of distilled water. Of this 10 c. c. 
(2.7f 5) = 0.200 grammes (3.08 grs.) NaCl. 

2. A solution containing 4 grammes (61.72 grs.) 
pure urea in distilled water, and diluted to 100 c. c. 
(27 f5). 

3. A solution of sodium sulphate saturated at ordinary 
temperature. 

4. A baryta solution as for urea (1 barium nitrate, 2 
caustic baryta). 

5. A solution of mercuric nitrate of such strength 
that 1 c. c. = 10 milligrammes (0.010 grammes) of 
sodium chloride, or 16.2 minims = .154 grains. 

To Prepare Solution of Mercuric Nitrate. Dissolve 20 
grammes (308.6 grs.) of pure metallic mercury in boilins: 
nitric acid, until a drop of the acid fluid dt)es not pre- 
cipitate when added to a solution of common salt. Con- 
centrate this fluid to a syrup}^ consistence over a water- 
bath, and dilute to nearly a litre of distilled water. 

To determine the strength of this solution, })lace 10 
c. c. (2.7 f^) in a beaker, and add 3 c.c. (48. G minims) of 
the solution of urea, and 5 c. c. (1.^5 f^) of the solutitMi o^ 
sodium sulphate. Into this allow tlio sc^lution o( mercuric 
nitrate slowly to drop from a burette. As each dr«^p 
touches the fluid, a wliite precipitate is seen to fall, which 
is promptly redissolved on stirring the mixture. Finally. 



94 PRACTICAL EXAMINATION OF THE URINE. 

however, a point is reached, when the opalescence remains 
permanent. This shows that all of the chloride of sodium 
is decomposed, and the insoluble precipitate of mercuric 
nitrate with urea has commenced to form. 

The number of cubic centimetres required to decom- 
pose .200 grammes (3.08 grs.) NaCl is then read off, and 
from these data, calculated as described under urea, the 
quantity of water to be added to make 10 c. c. correspond 
to .100 grammes sodium chloride, or 1 c. c. to .010 
grammes, or 10 milligrammes. 

Process, The phosphates and sulphates are precipi- 
tated from 40 c. c. urine by 20 c. c. baryta solution, as 
with urea. Of the filtrate, 15 c. c. containing 10 c. c. 
of urine are placed in a beaker-glass, and acidulated 
with 2 or 3 drops of nitric acid, just sufficient to cause 
it to turn blue litmus-paper red. 

The burette is then filled to with the mercuric nitrate 
solution, and this allowed to drop into the beaker con- 
taining the urine, until a permanent precipitate begins 
to form. 

The number of cubic centimetres used, multiplied by 
.010, gives the quantity of chlorine calculated as NaCl, 
in fractions of a gramme, whence the twenty-four hours' 
quantity is easily estimated. 

Molir's nitrate of silver method is preferred by Neu- 
bauer,* because Liebig's method, if not very exactly 

* Neubauer and Yogel, Analyse des Harns, YI Aufl., 1872, 
p. 169. 



INOIIGANIC CONSTITUENTS. 95 

carried out, gives incorrect results. There are re- 
quired : 

1. A cold saturated solution of neutral chromate of 
potash. 

2. A solution of nitrate of silver, such that 1 c.c = 
10 milligrammes NaCl. This is made by dissolving 
29.075 grammes (448.62 grs.) pure fused nitrate of silver 
in distilled water, and diluting to a litre. 

Process. Put 10 c. c. (2.7 f3) of the urine in a plati- 
num crucible, dissolve in it 1 or 2 grammes (15.43 or 
30.86 grs.) potassium nitrate free from chlorides, and 
evaporate the whole slowly to dryness. Expose the re- 
mainder, first to a gentle and afterwards to a strong 
heat until the carbon is completely oxidized, and the 
residue a white molten saline mass. The entire white 
mass is then dissolved in a little water, placed in a 
beaker-glass, the platinum capsule washed off into it with 
the wash-bottle. Dilute nitric acid is then carefully 
dropped into the alkaline fluid until it is faintly acid, and 
a small pinch of calcium carbonate is then introduced to 
make it neutral, the excess of lime filtered off. To tlie 
mixture, 2 or 3 drops of the potassium chromate solution 
are now added, and the silver solution allowed to flow in 
from the burette while stirring the mixture, until a dis- 
tinct red color remains. The color continues canary yellow 
until all the chlorides are decomposed. As each (\vo\) la Us 
into the urine, it must be carefully watched for the least 



\H\ VU\CV\C\\. KXAMINAIION OV TlIK T KM N K. 

tiniro o( rod surrouniiiiiix tlio proiMpitato of chloride oC 
silver; the very next drop after the eoniplete deeoni- 
position of the ehlorides, jxives a permanent reel color, 
due to llie presentH^ oC silver ehroniate. The number oi' 
cubic centinictres i^^nsunicd \ .010, will iiivc the amount 
o( chlorides, estimated as NaC^l in 10 c. c. urine, whence 
the total is calculated. 

\V1. riiosruATKS. The phosphates of the urine arc 
composcil partly o{ rarfhj/ i\ud ]>artly of alkali iir pho> 
phaics. The tormcr arc insoluble in water, but soluble 
in acids; they arc held in solution in acid urine by free 
carbonic acid, and precipitable from it by alkalies. The 
alkaline phosphates are soluble in water and not precipi- 
t4\ted fi\>m solution by alkalies. 

(T. The earthy phosphates are phosphates of lime and 
magnesia, and are contained in urine iu but small quan- 
tities — 1 to 1.5 irramme (,15.43 to 2o.l4 grains^ in twenty- 
four hours, 

Dftectiof) and Approximate Estimation. The presence of 
the earthy phosphates is shown by adding any alkali as 
caustic ammonia or potash. 

Their quantity may be appro.rimatcli/ estimated in the 
following simple way, given by Hofimann and Ultzmann. 
A test-tulH\ IG centimetres i,(>.2902 inchest long, and 2 cen- 
timetres (,.787 inch^ wide, is tilled one-third with clear or 
tiliereii urine, to which a few drojis of caustic ammonia or 
caustic potash solution are added and warmed gently over 



IXOKGANIC CONSTITUENTS. 97 

a spirit-lamp until the earthy phosphates begin to separate 
in flakes. It is then placed aside for ten or fifteen 
minutes for them to subside. If the layer of sediment is 
1 centimetre ^3937 inch; high, the earthy phosphates are 
present in normal amount ; if they occupy 2 to 3 cen- 
timetres '^.787 to 1.181 inch;, they ai-e increased; if, on 
the other hand, only a few flakes are visible, the earthy 
phosphates are diminished. 

Further, in normal urine the earthy phosphates are 
precipitated white, but if the urine contains abnormal 
coloring matter, they fall variously colored. If the urine 
contains blood coloring matter, the earthy phosphates 
appear blood red or dicroic; if there be present vegeta- 
ble coloring matters, as of rhubarb, senna, etc., they are 
colored rosy red to blood red, and by the biliary coloring 
matters yellowish-brown, and by uroerythrin gray. 

The earthy phosphates are deposited from alkaline 
urine, and a most important precaution here must be 
observed not to mistake such a deposit for an excess of 
phosphates. The phosphates may really be diminished, 
and yet in consequence of the reaction of the urine a 
copious deposit may be present. The possible precipita- 
tion of earthy phosphates by heat alone as a source of error 
in testing for albumen, has already been alluded to. This 
frequently occurs, and is best explained on the supposi- 
tion of Dr. Brett, that the eartliy phosphate.-^ are held in 
solution in urine by carbonic acid, which being dissipated 



98 PRACTICAL EXAMINATION OF THE URINE. 

by heat allows the phosphates to fall. It should be fur- 
ther stated, however, that Dr. Owen Rees believes the 
phosphates are held in solution by chloride of ammonium, 
which would also be dissipated by heat. Dr. Bence 
Jones attributed this precipitation to a neutralization of 
the excess of free acid in the urine by an alkali or free 
phosphate of soda. 

Clinical Significance. The earthy phosphates are in- 
creased in the urine by diseases of the bones, especially 
if extensive, as in osteomalacea and rickets, in chronic 
rheumatoid arthritis, in diseases of the nerve-centres, and 
after great mental strain ; but especially are the earthy 
phosphates increased by the food and drink, some con- 
tending that all variations in the earthy phosphates are 
due to this cause. In renal diseases, on the other hand, 
the phosphates are diminished. Earthy phosphates are 
often found deposited in conditions of dyspepsia and over- 
work, but this may generally be traced to changes in the 
reaction of the urine. 

b. The alkaline joliosphates, soluble in water and not 
^precipitated by ammonia or alkalies, form the chief bulk 
of the phosphates, averaging, according to Breed, 4 
grammes (61.72 grains) in the twenty-four hours, though 
Neubauer by volumetric analysis has seldom found more 
than 2 grammes (30.86 grains) in this period. Four 
grammes correspond to two grammes phosphoric acid. 
They are almost wholly made up of acid sodium pJios- 



INORGANIC CONSTITUENTS. 99 

pliate with possible traces of potassium phosphate. The 
acid sodium phosphate was believed by Liebig to bo the 
cause of the acid reaction of the urine. 

Approximate Estimation of Alhaline Phosphates. Accu- 
rately to estimate the alkaline phosphates, it would be 
necessary, first, to remove the earthy phosphates, which 
may easily be done by precipitating them with ammonia 
and filtering out. For approximate estimation, however, 
this is not necessary, since they are in the first place 
present in comparatively small quantity, and, secondly, 
do not vary much in disease. Practically, therefore, 
they are disregarded, and to a suitable quantity of urine 
placed in a beaker-glass about one-third as much of the 
magnesia fluid (p. 16) is added. All of the phosphates 
are thrown down in the shape of a snow-white deposit 
composed chiefly of ammonio-magnesian phosphate and 
amorphous phosphate of lime. If the entire fluid present 
a milk-like cloudy appearance, the alkaline phosphates 
may be considered present in normal amount ; if it is 
denser, more cream-like, there is an increase. If, on tlie 
other hand, the fluid is but slightly cloudy, transmitting 
light distinctly, the phosphates are diminished. 

Nitrate of Silver test, A solution of nitrate of silver 
added to urine throws down a yellow precipitate of phos- 
phate of silver, and cliloride of silver, l^oth are soluble 
in ammo)n((, the silver phosphate also in nitric acid, but 
not the chloride. If, therefore, a few drops oi' anunonia 



100 PRACTICAL EXAMINATION OF THE URINE. 

be added, they will promptly disappear. If now nitric 
acid, just sufficient to neutralize the ammonia, be added, 
the precipitate will again reappear ; but the moment the 
nitric acid is present in excess, the silver phosphate is 
redissolved, but the chloride remains in suspension. If 
now enough ammonia be added again to neutralize the 
nitric acid, the phosphate of silver will again fall ; but if 
an excess be added, the entire precipitate, including the 
chlorides, will be redissolved. 

Clinical Significance, The alkaline phosphates in the 
urine are influenced chiefly by the food, whence they are 
mainly derived ; phosphorus is also oxidized in the 
economy, and a small part of the phosphates is doubtless 
derived from the disintegration of nervous and muscular 
tissues. Any iucreased activity of vital processes, as 
inflammations and fevers, would, therefore, favor their 
increase. 

Volumetric Process for Phosphoric Acid, This process 
is based upon the facts that, 

1. When a solution of phosphate acidulated with 
acetic acid is treated with a solution of nitrate or acetate 
of uranium, a precipitate falls which is composed of 
uranium phosphate. 

2. When a soluble salt of uranium is added to a solu- 
tion of potassium ferrocyanide, a reddish-brown precipi- 
tate or color is developed. 

The solutions required are. 



INORGANIC CONSTITUENTS. 101 

1. A standard solution of sodium phosphate, made by 
dissolving 10.085 grammes (155.60 grs.) of well-erystal- 
lized sodium phosphate (l^^aJiFO^ + 12H.^0) in distilled 
water, and diluted to a litre (33.8 fg); 50 c. c. fl3.5 f3) 
then contain .1 gramme (1.54 grs.) P.^Og. 

2. Saturated solution of potassium ferrocyanide or 
filtering-paper saturated with the same and dried. 

3. Sodium acetate solution, made by dissolving 100 
grammes (1543 grains) sodium acetate in 100 c. c. (27 f5) 
pure acetic acid, and diluting with distilled w^ater to 1000 
c.c. (33.8 f§). 

4. Solution of uranium acetate, such that 1 c.c. will 
correspond to .005 grammes or 5 milligrammes phos- 
phoric acid. 

To prepare the Uranium Acetate Sohdion. Dissolve 20.3 
grammes (313.2 grs.) of pure uranic oxide in strong acetic 
acid, dilute with distilled water to nearly a litre. To deter- 
mine the strength of this solution, place 50 c. c. (13.5oz.) of 
the standard solution of sodium phosphate in a beaker with 
5 c. c. (1.35 f^) of the solution of sodium acetate and lieat 
in a water-bath to 90° to 100° C. (194° to 212° F.). The 
uranium solution is then allowed to run from a burette into 
the warm mixture until precipitation ceases. Then a drop 
of the mixture is carried by a ghiss rod into contact with 
a drop of the ferrocyanide of potassium solution on a white 
plate, or to a piece of the filtering--pa})er impregnated with 
it. If the reddish-brown i^i^ the uranium fiM'i-ocvanide does 
not appear, continue the cautious atldition o( the uranium 
9 



102 PRACTICAL EXAMINATION OF THE URINE. 

solution until the color responds to the test. The quantity 
used is then read off, being that which is suflScient to 
decompose sodium phosphate corresponding to .1 gramme 
(1.54 grs.) of P2O5, whence is calculated the amount of 
distilled water to be added to make 1 c. c. correspond to 
.005 gramme (.077 grain) of phosphoric acid. 

Process. Take 50 c. c. (1S.5 fj) of urine; add 5 c. c. 
(1.35 f 5) of the sodium acetate solution and warm in a 
water-bath as above. Fill the burette with the uranium 
solution, and drop it into the mixture while warm, test- 
ing with the ferrocyanide solution or papers as above. 
The number of cubic centimetres used multiplied by .005 
will give the phosphoric acid in the 50 c. c. of urine, 
whence calculate the quantity for the twenty-four hours. 

XVII. Sulphates. The sulphates found in the urine 
are those of soda and potash, the former preponderating. 
The quantity in twenty-four hours is 3 to 4 grammes 
(46.29 to 61.72 grains) corresponding to 2 grammes 
(30.86 grains) sulphuric acid. 

Detection and Aj^proximate Estimation, This is simple 
with any of the barium compounds which throw down 
a w^hite precipitate of barium sulphate. A little acid, as 
hydrochloric, should previously be added, in order to hold 
in solution the barium phosphate, which is otherwise 
thrown down, or the acid may be previously added to a 
solution of barium chloride. 

If to a small quantity of urine in a beaker-glass, one- 



iNORCMNic constitup:nt.s. 103 

third as much of the acidulated solution of barium 
chloride (1 part to 8 plus ^ a part hydrochloric acid; is 
added, and there occurs an opaque milky cloudiness, the 
proportion of sulphates is normal ; if the opacity is 
intense, and the whole mixture has the appearance and 
consistence of cream, the sulphates are increased ; if, on 
the other hand, there is only a slight cloudiness, so that 
light is still transmitted, the sulphates are diminished. 

Clinical Significance. The sulphates are derived partly 
from the food and partly from the tissues, are increased 
by the introduction of sulphur compounds, sulphuric 
acid and its soluble combinations, by an animal food, 
and by any causes producing increased rapidity of 
tissue change, as active exercise, the introduction of 
oxygen, febrile movements, and fevers. The greatest 
increase has been observed in meningitis, cerebri tis, 
rheumatism, and affections of the muscular system. They 
are diminished in an exclusively vegetable diet. 

The volumetric process for sitlpJmric acid depends upon 
the principle that a solution of chloride of barium will 
throw down a precipitate from a given quantity oi' urine, 
so long as any sulphuric acid is present ; and further, 
that in thus treating a specimen of urine acidulated with 
IICl, a neutral point is reached at which the filtrate 
will show a slight opacity as well with the sulphuric acid, 
as with the barium chloride solution. In such a lluid 
we are to suppose potassium chhu'idc, barium chloride. 



104 PBACTICAL EXAMINATION OF THE URINE. 

and potassium sulphate, balaiiciug each other. If now 
either barium chloride or potassium sulphate are added, 
it itself is decomposed, and barium sulphate precipitated. 
The solutions required are, 

1. Solution of barium chloride so concentrated that 1 
c. c. will precipitate exactly 10 milligrammes £[380^; 
prepared by dissolving 30.5 grammes (470.6 grs.) dry 
crystallized chloride of barium, and diluting to a litre 
(33.8 fg). 

2. Solution of potassium sulphate such that 1 c. c. = 
10 milligrammes H2SO4 ; prepared by dissolving 21.778 
grammes (336.03 grs.) chemically pure powdered potas- 
sium sulphate, dried at 100° C. (212° F.), and diluting 
to a litre (33.8 fg). 

Process. Place 100 c. c. (27 f5) urine, acidulated with 
20 to 30 drops hydrochloric acid, and heat it in a water- 
bath. When boiling, allow 5-8 c. c. of the barium solu- 
tion to flow in from a burette. Remove the heat and 
allow the precipitate to subside. If the fluid becomes 
rapidly clear, allow another cubic centimetre or two of 
the barium solution to flow in, reapply the heat and 
filter 10 to 12 drops of the urine into a small test-tube, 
add some of the barium solution, and observe whether 
there is a precipitate or not. If not, add to another por- 
tion a few drops of the potassium sulphate solution, by 
which we learn whether an excess of the barium solu- 
tion has been added or not. If, however, the barium 



INORGANIC CX)NSTITUENTS. 105 

solution still produces a precipitate in the portion re- 
moved for testing, the latter is returned to the V)eaker, 
and more solution allowed to fall in, determining the 
quantity somewhat by the intensity of the reaction in 
the test-tube, and the process repeated until no precii)i- 
tate takes place with the barium, and until a dlfjht 
cloudiness takes place when adding the potassium sul- 
phate to a portion of the filtered mixture. If the latter 
is an intense reaction say at 12 c. c, then we know that 
the correct point is somewhere between 11 and 12, and the 
process is repeated as far as 11 c. c, when it is continued 
very cautiously, adding only fractions — yo^'^s of a cen- 
timetre — until the right point is reached, whence the cal- 
culation is made as before. 



106 PRACTICAL EXAMINATIOX OF THE URINE. 



URINARY DEPOSITS. 

It has already been said that strictly normal freshly- 
passed urine, of acid reaction, contains no sediment 
Avhatever, except the faint flocculi of mucus which 
gradually subside towards the bottom, and entangle a 
few mucus-corpuscles and an occasional epithelial celL 
Should the urine, however, be alkaline, as is frequently 
the case three to four hours after a meal, it may be more 
or less cloudy at the moment it is passed, and quickly 
deposit a flocculent precipitate oi earthy phosphates, which 
may occupy considerable bulk. They will be found by 
microscopic examination to be made up of amorphous 
granules, and will quickly disappear on the addition of a 
few drops of any acid. 

But even urine which is strictly normal will, in the 
course of time, form deposits as the result of different 
reactions. These deposits differ w^ith the stages of such 
reaction, and should be perfectly understood by the 
student before he is ready to interpret any sediment 
arising from other causes. 

1. After normal urine, completely without sediment, 
has stood for a time, there is often observed a precipitate 
of amorphous granular matter, readily soluble by heat, 



UEINARY DEPOSITS. 107 

which is made up of acid urates of potash, soda, and 
ammonia, with which urates of lime and magnesia are 
occasionally commingled. (See lower portion of Fig. 10.; 
A little later they are replaced by rhombic crystals of uric 
acid, stained yellowish or yellowish-red. These are often 
associated with octahedral crystals of the oxalate of lime. 

The explanation given by Scherer of the occurrence of 
these deposits, is that of the so-called acid fermentation, 
in which, through the agency of the mucus of the blad- 
der, acting as a ferment, are formed lactic and acetic 
acids out of the coloring and other organic matters. 
These take aw^ay a part of the base from the neutral or 
alkaline urates, and produce first the more insoluble acid 
urates named above, which are deposited ; later they 
combine with the remainder of the base also, and leave 
the crystalline uric acid sediment. 

As though favoring this so-called acid fermentation, 
there are also often found at this stage in urine, spores of 
torida cerevisece — the yeast fungus — small, oval, transpar- 
ent, structureless cells, to be again referred to. Further 
sufficient proof that such fermentation takes place is, 
however, wanting. 

A much more satisfactory explanation of the occur- 
rence of these deposits, has been offered by Voit and 
Hoffman,* who attribute the decomposition of the ba^ic 

"^' Ncubauor and Yogel, Aiuilyso dos Ilarns, vi Aufl., 1872, 
p. 113, from Zoitschrift fiir Analyt. Oheinio, lid. 7, p. ol)7. 



108 PRACTICAL EXAMINATION OF THE UEINE. 

urates to the acid phosphate of soda, the excess of 
phosphoric acid playing the part of the acetic and lactic 
acid in the fermentation theory, and decomposing the 
alkaline urates in the same way and with the same 
results. They prove their position by an artificial pro- 
duction of the same results, by adding a solution of acid 
phosphate of soda to a solution of basic urates. The 
extent to which the reaction goes will depend upon the 
quantity of acid phosphate of soda present, and the length 
of time which has been permitted for the reaction to take 
place. It is possible also for the latter to begin at the 
moment of secretion, and to continue in the bladder, 
causing deposits of acid urates and uric acid to appear 
as "gravel" or "sand" immediately after the urine is 
passed. Such a condition would be pathological. Accord- 
ing to these authors, a more rapid action of the acid so- 
dium phosphate produces an amorphous precipitate, and 
a slower separates the crystalline uric acid. The more 
rapid reaction may be induced by a more abundant 
separation of the acid sodium phosphate or a greater con- 
centration of the urine. 

In the course of these changes, also, the acidity of the 
urine is diminished, and it may become neutral and even 
alkaline before the phenomena of the next stage to be 
described — the alkaline fermentation — set in. 

2. After a still longer but variable period, which is 
shorter in warm weather and longer in cold, we have the 



URINARY DEr08IT>S. 109 

so-called alkaline fermentation, which is a real fermenta- 
tion. This, in which decomposing mucus is also thought 
by some to be the ferment, is ascribed by Tieghem"^ to 
the action of a little torula, structureless, and without a 
cell-wall, which multiplies by budding, not at the surface 
but within the urine or at the bottom of the vessel, where 
it with the deposited salts forms a white sediment. In 
this fermentation we have the urea converted into car- 
bonate of ammonia, as already explained, by the addi- 
tion of two equivalents of water.f As the result of this 
conversion, the urine is rendered highly alkaline, and a 
further change in the character of the sediment takes 
place. At the very beginning of the reaction, w^hen the 
urine may still be neutral or even weakly alkaline, the 
uric-acid crystals begin to dissolve and to change their 
form so as to become more or less unrecognizable, while 



''^ Neubauer and Yogel, Analyse des Hams, vi Aufla^^c, 1872, 
pp. 110 and 130. 

f An explanation of the delay which sometimes occurs in the 
appearance of these phenomena is based on the recognition o( 
the multiplication of these spores as the cause of the fermenta- 
tion. If infusoria are simultaneously developed, the urea is 
more slowly converted, and if the surface of tlie urine happens to 
be covered with other plant vegetation, as is sometimes the case 
(mildew), the urine may remain acid for niontlis in consequence 
of the interference with the access of oxygen, on tlu' pri'SiMice o( 
which tlie spore is dependent for its growth and multiplication. 

10 



110 PRACTICAL EXAMINATION OF THE URINE. 

on their fragments may often be seen to adhere prismatic 
crystals of urate of soda and dark spheres of urate of 
ammonia. (Fig. 10.) As the reaction becomes alkaline, 

Fig. 10. 




Prismatic crystals of sodium urate, spherules of ammonium urate and amor- 
phous urates with octahedral crystals of oxalate of lime. (Ranke.) 



the uric acid altogether disappears, and the field becomes 
crowded with granules of amorphous phosphate of lime, 
beautiful triangular prisms (" coffin-lid" shaped crystals), 
and their modifications, of the triple phosphate of am- 
monia and magnesia, and opaque black balls of urate of 
ammonia often beset with spiculse (Fig. 11) ; the spores 
referred to are also often present, while millions of 



URINARY DEPOSITS. 



Ill 



bacteria vibrate slowly along, or form granular aggrega- 
tions about a fragment of organic matter, and an occa- 
sional infusorium darts across the field of view with 
magnified celerity. Commonly, however, the interme- 



FlG. 11. 




Spiculated spherules of ammonium urate along with octahedral crystals of 
the oxalate of lime. (Ranke.) 



diate stage is lost sight of, and the stage just described 
is the only one seen in the alkaline fermentation. Such 
urine has an ammoniacal and putrescent odor, is cloudy 
from the suspended phosphate of lime and bacteria, and 
exhibits to the naked eye an abundant white iK^posit. 

Either of the above set of changes may take place 
within the economy, in the pelvis of the kidiioy or in the 
bladder, and as such become pathological stales whicli are 
constantly met with in practice, tlu^ tir>i in the condition 



112 PRACTICAL EXAMINATIOX OF THE URINE. 

of uric acid gravel or calculus with its iucident suffering, 
and the second in the phenomena of irritation and inflam- 
mation, more particularly of the bladder, due to obstruc- 
tion by stone, stricture or malignant disease. It also seems 
to be a matter of modern observation that the germs of the 
fungi above alluded to, which seem to have a very close 
relation to the j)henomena described, either as cause or 
eflect, may be introduced from without by the use of 
imperfectly cleansed catheters, sounds or similar instru- 
ments. 

With this preliminary knowledge of the rationale of 
the causation of a large proportion of urinary deposits, 
we are ready to take up their detailed consideration. 

-Classification of Deposits. Efforts have been 
made to classify sediments on different bases, that is, on 
the ground of their external naked-eye characters as to 
bulk, color, weight, etc., again with regard to their na- 
ture and origin, whether organized or unorganized, crys- 
talline or amorphous, and finally as to the reaction of 
the urine in which they are found. 

The simplest division is into unorganized and organ- 
ized. A further division of these groups into crystalline 
and amorphous, seems to separate groups which are natu- 
rally associated, and is therefore omitted. 



UKINAllY DEPOSITS. 



I. UNORGANIZED. 



1. Uric acid (crystalline). 

a. Acid sodium urate (amorphous, oc- 
casionall}^ crystalline). 
' h. Acid potassium urate (amorphousj. 



2. Uric acid com- 



pounds. A • 1 1 • <L / I, X 

^ c. Acid calcium urate; (amorphous). 

d. Acid ammonium urate fcrystallinej. 
3. Oxalate of lime (crystalline). 

a. Ammonio-magnesian phosphate 

(crystalline). 
h. Calcium phosphate (amorphous 

and crystalline). 

5. Carbonate of lime (crystalline). 

6. Leucin and tyrosin (crystalline). 

7. Cystin (crystalline). 



4. Earthy phosphates, 



II. ORGANIZED. 



1. Mucus and pus. 

2. Epithelium. 

3. Blood. 

4. Pigment flakes. 

5. Casts. 



6. Spermatozoids. 

7. Eungi and infusoria. 

8. Elements of morbid growths. 

9. Entozoa. 



I. UNORGANIZED SEDIMENTS. 

1. Uric Acid. — Occurrence^ etc. Uric acid presents 
itself as a sediment of small bulk, sinking to the bottom, 
but sometimes adhering also to the sides of the glass. 
The individual crystals are often large enough to be seen 
by the naked eye, and in their aggregation ot'ien t'orm 
masses so large as to be characterized by the terms 
"sand," "gravel," " red-pe[)per grains." This hitter 



114 PRACTICAL EXAMINATION OF THE URINE. 

term is based upon the red or yelloivish-red coloration 
Avhich uric acid crystals in urine exhibit. 

They are found perfect only in acid urine, often at the 
end of the so-called acid fermentation, in urine concen- 
trated from any cause, and Avhere there is a pathological 
increase in the production of uric acid due to imperfect 
oxidation or assimilation. 

Recognition, The typical shape of a uric acid crystal 
may be said to be a four-sided rhomb, and six-sided plate. 

Fig. 12. (After Harley.) 




More usual forms of uric acid crystals. 



But it is comparatively seldom that the typical forms are 
observed, the latter shape being somewhat rare, and the 
angles of the former being generally so rounded off that 



URINARY Di:r081T8. 



115 



the crystal assumes an ovoid or "whetstone" shape, of 
very different sizes, some behig mere points with powers 
of 200 to 300 diameters, while others are large enough to 
be seen by the naked eye. Further shapes are those of 
sections of a barrel, envelope, spear, fan, of a comb with 
teeth on two sides, quadrilateral prisms with terminal 
planes, dumb-bells, and even other forms. What are 
commonly called "dumb-bells" of uric acid may be 



Fig. 13. (After Harley.) 

h 



I 




INForo unusual forms of uric acid crystals. 



rather compared to a tui't of hay const riciod at its mid- 
dle. These varied forms, practice soon tcaclios one to 
recognize, even though they may deviate much tVoui the 



116 PKACTICAL EXAMIXATIOX OF THE UKIXE. 

typical shape. Uric acid crystals as observed, are almost 
invariably colored, and can generally thus be distin- 
guished from other deposits. Dr. Beale"^ states that two 
or three instances have come under his notice in which 
thev were not colored. Uric acid crystals are met singly, 
but very commonly they are aggregated, forming beau- 
tiful rosettes and other shapes of aggregation of such 
size, as to be easily visible to the naked eye — as the 
"red-pepper grains" already alluded to — and to give 
pain in their transit through the ureter. 

Fig. 12 exhibits the more usual varieties of uric acid, 
and Fig. 13 some of the rarer forms. (See pages 114, 115.) 

Tests for Uric Acid. Whenever a crystalline deposit 
is of doubtful character, and suspected to be uric acid, 
if the latter, it will respond as follows: 

1. Insoluble in cold or hot water, it will readily dis- 
solve in the alkalies, soda, potash, or ammonia. If then 
the alkaline solution be treated with an excess of acetic 
acid, in a few hours typical whetstone-shaped forms will 
crystallize out. 

2. Or the sediment may be placed on a glass slide, and 
treated with the murexid test as described on page 86. 

The dumb-bell crystals of uric acid occasionally met 
with may be distinguished from the dumb-bell crystals 

^ Kidney Diseases and Urinary Deposits, Philadelphia, 1869, 
p. 371. 



UIMNAJIY DEPOSITS. 117 

of the oxalate of lime, by the characteristic shape already 
referred to, by their larger size, their darker color, and 
their solubility in alkalies. 

2. Uric Acid Compounds, a. Sodium urate, mainly 
amorphous, is ^sometimes crystalline. It always forms a 
part, and, according to Bence Jones, a predominant part 
in the pulverulent, heavy, variously tinted, and generally 
bulky deposit of the mixed urates known as '' brick- 
dust" or " lateritious " sediment. The degree of colora- 
tion of this sediment depends upon that of the colora- 
tion of the urine whence it falls. From pale urine of 
low specific gravity, 1010 to 1014, an almost white sedi- 
ment separates, falling very slowdy, and producing there- 
fore an opaque, cloudy appearance in suspension, but 
readily disappearing on the application of heat ; from 
urine of an amber color, and specific gravity of about 
1018, the urates deposited are faiun-coloYcd ; and from 
high-colored urine of higher specific gravity, we have the 
true red "brickdust" sediment. The sediment is found 
in faintly acid urine, or urine in which the acid ferinen- 
tation has only commenced, and has not been operating 
so long as completely to remove the base, and cause the 
crystalline uric acid to be deposited. It is found also in 
urine concentrated from any cause, or where it has cooled 
down considerably below o7° C. (98i° F.\ or where there 
is defective oxidation or assimilation, as in fevers. 

Iieco(j)iitlon. By far most frequently do we tind sodium 



118 PEACTICAL EXAMINATION OF THE URINE. 

urate in fine amorphous granules, by their shape in no 
wise distinguishable from other fine granular matters, 
requiring therefore the chemical tests for their discrimi- 
nation. The adhesion of these fine granules to partially 
coagulated shreds of mucus sometimes gives rise to an 
appearance resembling finely granular casts (see Fig. 10), 
which is readily detected by the experienced, but which 
may mislead the beginner. The careful application of 
heat, or the addition of a drop of acetic acid, will 
promptly dissipate the illusion. These granules of so- 
dium urate also assume a larger size, and become little 
spherules, sometimes provided with spicules (see Fig. 11), 
which are considered by some (G. Bird, Beale) to be 
spicules of uric acid (Beale, Figs. 104 and 105, opposite 
page 354). Other spherules are provided with project- 
ing and curved processes, and are believed by Hassall 
(second edition, page 75) and Thudichum (page 102) to 
be composed of urate of soda throughout. That the 
spines were also urate of soda, Thudichum considered 
evidenced by their solubility in water. A modified form 
of the latter is probably the irregularly star-shaped crys- 
tal in Dr. Beale's Fig. 110, from the urine of a patient 
suffering with peritonitis. But all of these forms of 
spherules with straight and incurved processes (thorn- 
apple shapes) are put down by the German observers 
(Neubauer and Vogel, Hoffmann and Ultzmann) as crys- 
talline forms of urate of ammonia, in which I am inclined 



URINARY DEPOSITS. 119 

to concur, at least with regard to those which are found 
at the stage of reaction intermediate between the acid 
and alkaline fermentations, or perhaps rather at the be- 
ginning of the latter, when ammonia makes its appear- 
ance, and is accompanied by the ammonio-magnesian 
phosphate. But any spherules which occur early in the 
acid reaction, or before it is possible for any ammonia to 
be present, are probably sodium urate. 

The sodium urate is also rarely found in dumb-hells 
which are also striated and broad at the extremities like 
those of uric acid, but less disposed than the latter to 
break up at the extremities into individual acicles (Atlas 
of Hoffmann and Ultzmann, Taf IX). One-half of one 
of these dumb-bells, viewed from above, would be fan- 
shaped. 

Under the same circumstances, at the end of the acid, 
and at the beginning of the alkaline fermentation, do we 
also have the true prismatic crystcds o^ ^q,\^ sodium urate, 
arranged in star-like masses (Fig. 14, p. 120). 

b. Acid potassium urate is also amorphous, very sohi- 
ble, and occurs under the same circumstances as sodium 
urate, as a constituent of the mixed waters. 

c. Acid calcium urate occurs very seldom, and in small 
quantity, of white amorphous powder, along with the 
mixed urates. It is with difficulty soluble in water, ami 
known to have lime for its ba>e, by leaving a residue ot' 
calcium carbonate after incineration. 



120 PRACTICAL EXAMIXATIOX OF THE URIXE. 

d. Acid ammonium urate. — Occurrence. This is found 
along with amorphous earthy phosphates and crystals of 
the triple phosphates of ammonia and magnesia, in urine 

Fig. 14. 




Prismatic crystals of sodium urate, spherules of ammonium urate and amor- 
phous urates with octahedral crystals of oxalate of lime. (Ranke.) 



in which the alkaline fermentation has commenced. It 
is the only urate found in alkaline urine. 

Recognition. It is crystalline, and presents itself in 
the shape of smooth and the characteristic " thorn-apple" 
spherules (Figs. 10 and 11), which serve easily to distin- 
guish them. They are dissolved in hot water, and dis- 
solve with the evolution of uric acid crystals, by hydro- 



URINAIIY DEPOSITS. 121 

chloric or other acid. Liquor potassa, added to them, 
evolves the odor of ammonia, and they give the miirexid 
reaction with nitric acid and ammonia. 

Tests. Though the acid urates are much more insolu- 
ble than the neutral urates remaining in solution, requir- 
ing 124 parts of boiling water, and 1150 of cold, they 
readily dissolve on the application of heat to the slide or 
test-tube containing them. They are dissolved also by 
the alkalies, liquor potassa, or soda. Treated with nitric, 
hydrochloric, or acetic acids (the diluted are better on 
account of their slower action), they dissolve with the 
subsequent crystallization of uric acid. They also re- 
spond to the murexid test. 

3. Oxalate of Lime. — Occurrence. The oxalate of 
lime crystals are most frequently met in acid urine, often 
therefore alongside of crystals of uric acid, but they may 
also be met in alkaline urine, along with crystals of the 
triple phosphate. They are particularly abundant in the 
urine after a meal of rhubarb plant, after the use of 
tomatoes, and other vegetables containing oxalic acid. 
There are no means by which the presence of oxalate of 
lime may be foretold before a microscopic examination 
of the urine is made. It never forms a dei)osit ap})roc'i- 
able to the naked eye, and most conunonly the crystals 
do not descend to the bottom of the glass, but are caught 
as it were by the tlocculi of mucus which float townrds 
the bottom, rather than occu|)y it. 



122 PRACTICAL EXAMINATION OF THE URINE. 

Recognition. Two forms of oxalate of lime crystals 
are met, the octahedra and the dumb-bell crystals. The 
former appear somewhat differcDtly according as they 
are seen in the longer diameter or in the shorter. They 
may be said to be made up of two four-sided pyramids, 
placed base to base, and when viewed in the longer di- 
ameter, may readily be detected as such by the micro- 
scope. When seen in the opposite direction, their char- 
acteristic appearance is that of a square, crossed obliquely 
by two bright lines, and if the crystal be very small, it 
will appear as a square with a bright point in the centre — 
a characteristic appearance by which one may soon learn 
to detect them, even when they are very small. They 
are often seen in aggregations of three, four, or more, 
closely adherent, and forming as it were microscopic cal- 
culi. 

Fig. 15. (After Harley.) 




The dumb-bells, very much more rarely met with, are 
highly characteristic, and although we have spoken of 



UKINARY DEPOSITS. 123 

dumb-bells of uric acid and of ammonium urate, neither 
of the latter present the typical dumb-bell appearance 
like those of the oxalate of lime. To these are found 
also allied forms, circular and oval shapes, with darker 
or brighter centres, and some with partial concavities at 
the sides, as though passing over into dumb-bells. 
Dumb-bells are also met with in the urine aggregated, 
forming microscopic calculi, which go far to explain the 
incipient formation of calculi. 

Chemical Characters, The form of crystals of oxalate 
of lime is so characteristic, that there is seldom occasion 
to make use of chemical tests to determine them. The 
only crystals which at all resemble them, are certain 
forms of the triple phosphate. These are small crystals, 
modifications of the typical triangular prism, with its 
bevelled ends, in which the body of the prism is exceed- 
ingly short, or as it were almost left out, so that the two 
inclined triangular ends closely approach each other, and 
form a crystal like that of the octahedron of oxalate of 
lime. Their nature may, however, be suspected by the 
character of the larger crystals around them, for they 
never occur alone. Moreover, they are promptly dis- 
solved by the addition of acetic acid, while the oxalate 
of lime is totally insoluble in this acid. The oetahedra 
are highly insoluble in water, in alkalies, and in the 
vegetable acids, including acetic, but are so hible in thr 
mineral acids. The dumb-bells, after a prolonged action 



124 PEACTICAL EXAMIXATIOX OF THE UEIXE. 

in acetic acid, yield their crystalline matter, leaving a 
framework, which maintains the original shape of the 
crystal. This in fact explains, perhaps, the shape of the 
crystal. It has been shown by Mr. Eainey and others, 
that the presence of organic matter, as mucus, interferes 
with crystallization in the regular manner. The dumb- 
bells of oxalate of lime can readily be distinguished from 
the dumb-bells of uric acid or urates by the solubility of 
the latter in alkalies. 

The acid phosphate of soda, according to Xeubauer,"^ 
possesses a power of solution over the oxalate of lime, 
often holding it in solution, and he gives a method by 
which the latter may be obtained from solution in the 
urine by its agency, as follows : 4 to 600 c. c. (108 to 
162 f5) of the urine to be tested is treated with solution 
of chloride of calcium, supersaturated with ammonia, and 
the precipitate dissolved in acetic acid. After twenty- 
four hours, the precipitate arising, which nearly always 
contains uric acid, is placed on a filter, washed with 
water, and a few drops of hydrochloric acid poured upon 
it. The latter dissolves out the oxalate of lime jDresent, 
and leaves the uric acid on the filter. The filtrate is then 
diluted in a test-tube with 15 c. c. (2.83 f5) of water, 
and overlaid most carefully, by means of a pipette, with 
very dilute ammonia in sufficient quantity. At rest, the 

^ Neubauer and Vogel, op. citat, p. 174. 



URINARY DEPOSITS. 12o 

two fluids gradually mingle, and after twenty-four hours 
the oxalate of lime present will have collected at the 
bottom, and octahedra of great beauty may be studied 
with the microscope. 

Neubauer says he has many times, in this manner, ob- 
tained considerable quantities of oxalate of lime, where 
there was previously no deposit whatever. He has, how^- 
ever, in other instances with normal urine, obtained neg- 
ative results, so that he is unable to decide whether oxa- 
late of lime should be considered a normal or abnormal 
constituent of urine. 

There is no doubt but that oxalic acid is at times, at 
least, secreted by the kidneys, and meeting immediately 
the lime salts for which it has a strong aflinity, forms 
the crystals we are considering ; for both octahedra and 
dumb-bells are not infrequently found in the uriniferous 
tubules of the kidney and even in tube-casts. Schunck 
has attempted to show^ that the oxalate of lime is formed 
during the decomposition of urine from the oxalate of 
ammonia, but Neubauer says the oxalate of ammonia is 
converted into carbonate of ammonia. Others, as Owen 
Rees, Aldridge of Dublin, Wohler, and Frericlis, anege 
that oxalate of lime is derived from a decomposition of 
uric acid and urates. Their experiments would seem to 
show this, and it is undoubtedly the case that deposits o'i 
oxalate often make their ap[)oaninco in urine s(>nio time 

11 



126 PRACTICAL EXAMINATION OF THE UKINE. 

after it has been passed. Two sources must, therefore, be 
admitted, one within the organism and one without. 

Clinical Significance. There is no disease with which 
the oxalate of lime is particularly associated, nor can 
deposits of it be considered indicative of derangement. 
Abundant deposits of oxalate of lime are found in the 
urine of persons who are typically healthy. On the 
other hand, it is apt to occur where there is mal-assimi- 
lation, and hence dyspeptics are often found having 
oxalates in their urine, as a result rather than a cause of 
the affection from which they suffer. 

When there is evidence of renal calculi in descent from 
the pelvis of the kidney, and oxalates are found in the 
urine, especially if they are found in the aggregations 
referred to, the latter may afford explanation of the 
nature of the stone. Unfortunately, too often there is no 
sediment whatever attending the descent of a calculus, 
and we must, therefore, determine its nature without such 
aid. A careful examination should, however, ahvays be 
made of the urine in nephritic colic, as valuable infor- 
mation is at times at least furnished by it, especially in 
the uric acid lithiasis where uric acid sediment is often 
found. 

4. Earthy Phosphates. — Occurrence. These deposits 
are found only in very feebly acid or alkaline urine, and 
are the more abundant, the more advanced is the stage of 
alkaline fermentation. They appear to the naked eye as 



URINABY DEPOSITS. 



127 



bulky opaque white deposits, unless they are accompanied 
by blood, which then more or less tinges them. The urine 
itself is apt to be turbid from the presence of amorphous 
phosphate of lime in suspension, to have an ammoniacal 
and sometimes a fetid odor, though not necessarily. They 
are especially abundant in the urine of all irritative affec- 
tions of the bladder, and often attend diseases of the 
spinal cord. The earthy phosphates are the triple phos- 
phate or ammonio-magnesian phosphate and the phosp/hate 
of lime. 

a. The Ammonio-magnesian Phosphate (MgNH^PO^ 

Fig. 16. (After Harley.) 




6H.P), or triple phosphate, is a crystalline deposit, oi^ 
which the typical form is a triangular prism vFig- U)") 



128 PRACTICAL EXAMINATION OF THE URINE. 

with bevelled ends, very characteristic and easily recog- 
nized. 

In addition to this, there is an infinite variety of modi- 
fications, with one or more corners removed, the body of 
the crystals variously shortened, etc. Among these forms 
is the small crystal already referred to as being possibly 
mistaken for the oxalate of lime. There are also some- 
times found beautiful star-shaped (Fig. 17) crystals of 

Fig. 17. (After Harley.) 




triple phosphate, which gradually undergo conversion 
into the prisms, and between these two there are many 
intermediate forms. 

b. Phosphaie of Lime, amorphous Ca3(P04)2 ; crystal- 



UEINARY DEPOSITS. 129 

line CaHPO^. Phosphate of lime is most frequently 
found amorphous under the same circumstances under 
which the triple phosphate is found. It is, however, fre- 
quently deposited from normal urine in which it is held 
in solution during the acid reaction by -the acid phosphate 
of soda, or carbonic acid, or by both. At any rate let 
the acid reaction be wanting, as it is three or four hours 
after a meal, and a copious deposit of calcium phosphate 
often takes place, which is increased by boiling. In other 
instances, a urine may be acid in its reaction, and the 
boiling, apparently by driving off the carbonic acid, will 
cause the phosphate to go down. These deposits have 
more than once been spoken of as possible sources of 
error in testing for albumen, but they promptly disappear 
on the addition of acids. The color of the phosphate of 
lime alone is not snow-white as that of the triple phos- 
phate, but rather yellowish. 

Not infrequently we meet in urinary deposits cri/stalline 
phosphate of lime (Fig. 18), which occurs sometimes alone 
and sometimes along with the triple phosphate. It is 
also met in urine of a weak acid reaction, but strongly dis- 
posed to take on the alkaline fermentation. The occur- 
rence of crystalline phosphate of lime seems peculiar to 
certain individuals, and Hoffmann and Ultzmann have 
met persons perfectly healthy, who, in the suninier 
months, have almost daily deposits of crystalline [)hos- 



130 PEACTICAL EXAMIXATIOX OF THE UEIXE. 

phate of lime. They are frequently associated with 
octahedra of the oxalate of lime. 

Fig. is. 




Crystalline and amorphous phosphate of lime. 



Recognition. The isolated crystal of phosphate of lime 
may be said to be Kedge-shaped or even conical, from 
which form there are, however, variations. But their 
characteristic feature is in their arrangement, which is 
that of a circular rosette, in which the apices of the 
numerous crystals forming it all point to the centre. 
Phosphate of lime is also tbund in the shape of spherules 



URINARY DEPOSITS. 131 

or even diiwh-helk. The latter arc said by Dr. Beale 
(Kidney Diseases and Urinary Deposits, p. 857; to be 
deposited in decomposing mucus, not only from the 
urinary tract, but from other surfaces, as the gall-bladder. 
Dr. Beale figures such dumb-bells in his Plate xxi, Figs. 
116 and 118. 

Chemical Characters. All of the phosphates are dis- 
solved by acids, but are insoluble by alkalies and heat, 
whereas the uric acid salts are dissolved by both these 
agencies. The small triple phosphate crystals, which 
resemble those of oxalate of lime, dissolve quickly in 
acetic acid, while the octahedra are untouched by it. 
Uric acid itself could scarcely ever be confounded with 
phosphates, occurring, as it does, in urine of different re- 
action ; but if it were necessary to discriminate them, the 
former are dissolved by alkalies, the latter not. More- 
over, the murexid test will not respond to phosphates, but 
will to uric acid. 

5. Carbonate of Lime is a very rare deposit in human 
urine, but found abundantly in horse's urine. When 
present, it occurs in small s})heres, and is detected by its 
effervescence with acetic acid. 

6. Leucin and Tyrostn. — Occurroicc, These crystal- 
line deposits are only found in urine which is loaded with 
biliary coloring matters, since they attend only uiavo 
destructive diseases of the liver, especially acute yellow 
atrophy and phosphorus poisoniuu*. 



132 PRACTICAL EXAMIXATIOX OF THE URIXE. 

Recognition. If suspected in urine presenting the 
above characters, it may be slightly evaporated, when 
the crystals will be deposited if present. 

Leucin presents itself in the shape of more or less 
yellow-tinged, highly refracting spheres, which may at 
first sight be taken for oil-drops, A little study will 
show them refracting light not quite so strongly, i. e., not 
possessing quite so wide a dark border ; and by suitable 
illumination, many of them will be found marked with 



Fig. 19. 




Leucin spheres and tyrosin needles. 



radiating and concentric strise. The spherules further 
exhibit a peculiar disposition to aggregate, appearing 
partially to merge where two edges come together. 

Tyrosin is found in the shape of very fine needles 



URINARY DEPOSITS. 133 

arranged in tufts or ".s7iea/'Mike collections, often cross- 
ing each other and intersecting at their constricted 
central portions (Fig. 19). 

Chemical Characters. Leucin spheres, unlike oil-glob- 
ules, are insoluble in ether, and further are soluble in 
caustic alkalies, but not in cold mineral acids. Tyrosm 
may be recognized by Hoffmann's test. A suspected de- 
posit is boiled in an excess of water. To the boiling 
fluid, a few drops of a solution of mercuric nitrate are 
added, and there arises a red precipitate, while the super- 
natant fluid is colored red to purple-red. 

7. Cystin (C3H.NSO2). — Occurrence and Recognition . 
Cystin is a rare urinary sediment. Crystalline, forming a 
whitish or dirty yellowish-gray deposit, which on micro- 
scopic examination is found to be made up of regular six- 
sided tablets of different sizes, often so arranged that one 
of smaller size is superimposed on one of larger, and this 
upon a still larger, and so on ; but it also occurs in 
irregular masses (Fig. 20). It is usually met in a pale 
urine, both acid and alkaline, developing in decompo- 
sition the odor of sulphuretted hydrogen, as well as that 
of ammonia, the former doubtless derived from the sul- 
phur contained in the cystin. It occurs as a separate 
urinary deposit as well as accompanying cystin calculus, 
which seems sometimes to be herodittuy. 

Chemical Characters. It is solul)le in anunouia, and 
by this property may be distinguished from siniihir six- 

12 



134 PRACTICAL EXAMINATION OF THE URINE. 

sided crystals of uric acid, which not unfrequently accom- 
pany it. Upon spontaneous evaporation of the ammoni- 
acal solution, the six-sided crystals reappear, showing that 
it is simply dissolved in the ammonia, and not in chemical 
combination with it. It is also soluble in acetic, and 
solution of oxalic acid, while uric acid is uninfluenced 



Fig. 20. (After Harley.) 




by them. It is soluble in potash, and insoluble in solu- 
tion of carbonate of ammonia, and therefore may be 
precipitated from an acid urine by the alkaline fermen- 
tation ; under these circumstances it would be accom- 
panied by amorphous phosphate of lime and crystalline 
phosphate of ammonia and magnesia, with neither of 
which is it likely to be confounded. In a mixed deposit 
containing six-sided crystals, the lime and triple phos- 
phate may be dissolved out with acetic acid, while the 
plates of cystin will remain. They may then be treated 
with ammonia and hydrochloric acid, to distinguish them 
from uric acid. 



URINARY DEPOSITS. L'35 



II. ORGANIZED DEPOSITS. 



1. Mucus AND Pus. Mucus, even if present in con- 
siderable amount, could not be recognized by its own 
properties, it is so transparent and similar to urine in 
its refractive index. It is visible only through the acci- 
dental morphological constituents which it more or less 
constantly holds in suspension. These are the so-called 
mucus-corpuscles and epithelium from all parts of the 
genito-urinary tract, as well as crystals of the oxalate 
of lime, granules of sodium urate, and even crystals of 
uric acid. In strictly normal urine the first two w^ould 
alone be present, and in very minute quantity. These 
cause mucus to appear, when present in normal amount, 
as a delicate cloud, often barely visible, floating ioimrds 
the bottom rather than at the bottom of the vessel. 

By the action of acetic acid, the mucin, an element of 
mucus which is comparable to albumen, though not co- 
agulable by heat, is precipitated in the shape of delicate 
fibrillated bands, which are sometimes tortuous, and again 
appear as delicate threads known as mucin threads. If 
a little iodine and iodide oi' potassium be added to such 
acetic acid, they are made even more distinct. Tartaric 
acid and very dilute solutions of the mineral acids have 
the same effect, while an excess of the same will rodis- 
solve the precipitate ; so too the mineral acids will dis- 
solve the coaii;ulum of acetic acid, while an excess ot'the 



136 PRACTICAL EXAMINATION OF THE URINE. 

latter will not dissolve it. These coagula may sometimes 
be found in urine to which no acids have been added, 
being jDrobably produced by the action of the acids 
developed in the acid fermentation. Under these cir- 
cumstances they are particularly apt to be studded with 
granular urates, which may cause them to be mistaken 
. for granular tube-casts, but they are generally very much 
narrower than the latter, and the addition of a little 
warmth, hydrochloric acid or alkali will quickly dissolve 
the granules. (See Fig. 10.) 

As the result of irritation of any part of the genito- 
urinary tract, mucus is increased in quantity, when it 
assumes a thicker more ropy character, and becomes 
more or less opaque, but even here the opacity is due to 
the increased proportion of cellular element rather than 
to the mucus itself, which is always transparent. Under 
these circumstances, the opaque clouds of mucus are often 
enormously increased, and with them the adherent epi- 
thelial cells from the seat of irritation. AYhen thus in 
excess, mucus is apt to pervade more or less the entire 
mass of the urine rather than sink to the bottom, giving 
the entire fluid, therefore, a "glairy character. Mucus, 
however, seldom becomes very abundant without being 
attended by pus, as the causes producing them are but 
differences of degree. So long, however, as urine contain- 
ing mucus is without albumen, so long may pus be said 



UEINARY DEPOSITS. 137 

to be absent, as mucus iUelf contains no alhuw/m^ vihile jyan 
does. 

The Mucus- and Pus-corpuscle. The mucus-corpuscle, as 
it appears in urine, is a small, granular, spherical or nearly 
spherical cell, rather larger than a blood-corpuscle, that 
is .008 to .010 millimetres (-30^0 ^^ ^t'oir ^^ ^" inch) in 
diameter, containing one or more nuclei. In a healthy 
condition of mucous membrane, a mucus-corpuscle, how- 
ever it originates, is nothing more nor less than a young 
epithelial cell which has been pushed off before it has 
attained the characters of such cell in its development. 
As such, therefore, we must not too closely restrict its 
size, for who shall say where the mucus-corpuscle ter- 
minates and where the epithelial cell begins? As such 
a young cell, without morbid impression, simply arrested 
in its normal development, a single nucleus is more com- 
mon than it is in the ^i(s-corpuscle, of which the multiple 
nucleus may be said to be more characteristic. But here 
the difference ceases. For the pus-corpuscle, when young 
(that is, not the subject of fotty degeneration), is a cell 
exhibiting the same characters, and nu\y bo deiined in 
the same way. The fiict being that when a cell exliibit- 
ing the above characters, with one or multiple nuclei, is 
found upon a non-suppurating surface, it is callod :i 
mucus-corpuscle, while the same coll on a suppurating 
surface would be called a pus-corjiusolo. Thu<, while 
the two are physiologically distinct, thoy ixw anatoniioally 



138 PRACTICAL EXAMINATION OF THE UEINE. 

the same, the physiological difference being in this, that 
a pus-corpuscle is a cell too rapidly produced to be 
allowed to develop into the normal tissue of the part, 
while the mucus-corpuscle is, as it wer^, only accidentally 
arrested in its development. The same resemblance 
which exists between these bodies, exists between them 
and the white corpuscles of the blood, and to the whole 
class of cells to which the term leucocyte or white cell is 
conveniently applied. 

Fig. 21. 




Mucus- and pus-corpuscles before and after the addition of acetic acid. 

The Action of Reagents. The mono-nucleated mucus- 
corpuscle, which may be considered an older mucus- 
corpuscle, or young epithelial cell thrown off at a later 
period, usually exhibits its single nucleus distinctly, 
without the addition of a reagent ; but the majority of 
leucocytes have not their nuclei visible until acted upon 
by certain reagents, of which two acting similarly most 
interest us. These are water and dilute acetic acid. 

1. Action of Water. When water is added to the pus- 
or mucus-corpuscle, its first effect is to cause the latter to 
swell up, sometimes to twice the original size, next to 



UKINARY DEPOSITS. 139 

become smooth, the granules gradually disappearing, 
while the nuclei come forth with great distinctness. 
Finally, after some time the body of the cell becomes 
almost and then quite invisible, while the nuclei remain 
some time longer. The circumstances under which the 
corpuscle exists in urine are not quite identical, because 
in it we have a solution of organic and inorganic matters 
considerably denser than Avater, sp. gr. 1015 to 1025, and 
while the action is somewhat similar, it is very much 
slower ; and if the specific gravity of the urine should be 
very high, exceeding that of the fluid in the cell, there 
might be no effect or a contrary one, i. e., a shrinkage of 
the cell from an exosmosis of its contents. 

2. Acetic Acid, The action of dilute (20 per cent.) 
acetic acid is identical with that of water, except that it 
is very much more rapid, and the stage of distinct nuclei 
is reached much sooner. 

3. The caustic alkalies have a rapidly destructive efiect 
upon these corpuscles, destroying their morphological 
identity, and converting them into a gelatinous adherent 
mass. 

Uriiie containing pus deposits an opaque white sediment, 
which sinks rapidly to the bottom, so long as the reaction 
is acid and there is no mucus present. Such urine, when 
shaken up, becomes more or less opaque, accordini:- to the 
amount of pus which it contains. The o})ac'ity, as well 
as the deposit, often resembles that due to the pale i:ranu- 



140 PRACTICAL EXAMINATION OF THE URINE. 

lar urates, from which it is distinguished by the disap- 
pearance of the latter on the application of heat, while 
purulent urine deposits albumen under the same circum- 
stances. To a less degree does urine containing pus 
resemble that containing amorphous phosphate of lime, 
but the latter is dissipated by acids, while acids also 
precipitate the albumen from pus, and the microscope 
reveals millions of the granular cells already described 
as pus-cells, in many of which the nuclei are already dis- 
played in consequence of the action of water. 

Donne's test for jnis is based upon the reaction referred 
to between the alkalies and pus. It consists in the 
addition of liquor potassa to the deposit of pus after the 
supernatant urine is poured off. If the deposit is pus, 
it is promptly converted into a viscid gelatinous sub- 
stance resembling mucu'^, which adheres to the bottom of 
the test-tube, often permitting its inversion without falling 
out, and which, when it is forced to flow, does so in a 
continuous mass as the albumen runs out of a broken egg. 
If a portion of this glairy mass be examined under the 
microscope, the pus-corpuscles will be found to have 
been destroyed, or rather converted into the substance 
itself If the action has not been very long, or the pro- 
portion of alkali to the pus is small, the nuclei of the 
corpuscles may still be found as black dots in the mass, 
or a certain proportion of the corpuscles may preserve 
their integrity. 



UKINARY DEPOSITS. 141 

On this same reaction is based a most important change 
which urine containing pus undergoes after the alkaline 
reaction has set in. Through the agency of the carbonate 
of ammonia generated, precisely the same change is 
wrought, and the urine contains a deposit so ch)selv 
adhering to the bottom of the bottle that it is impossible 
to remove it with a pipette. It must be remembered that 
this is not mucus, although it so closely resembles it, and 
although microscopic examination may show the total 
absence of pus-corpuscles. These have been destroyed 
by the alkali. Care should be taken, therefore, to deter- 
mine the reaction of the urine before a mucoid deposit is 
decided upon, and if it is alkaline, another of acid reac- 
tion should be obtained. The glairy product referred to 
will be found dotted with glistening points, which on 
microscopic examination prove to be crystals of triple 
phosphate, while the supernatant fluid will be found to 
contain albumen, which is wanting in deposits of pure 
mucus. 

Frequently in diseases of the bladder, these changes 
take place within the organ, forming a gelatinous mass, 
which plugs up the urethra and makes it almost impos- 
sible to evacuate the bladder, thus greatly increasing the 
suiiering of the patient. In such cases the only remedy 
is to wash out the bladder with weak acid solutions, and 
having cleansed it, keep it so by their daily use. Mwn 



142 PRACTICAL EXAMINATION OF THE URINE. 

when acid at the time of being passed, these urines 
become rapidly alkaline afterwards. 

Sources of Pus in the Urine. Pus in the urine may 
come from any part of the genito-urinary tract. When 
descending from the pelvis of the kidney, as it often does, 
in impacted calculus, it is less apt to be mingled with 
mucus, the urine retains its normal reaction, and the pus 
is, therefore, readily miscible with the urine, and as 
promptly deposited from it. When coming from the 
bladder, if the urine is not already alkaline, it is apt to 
become so very quickly, and w^e have then the phenomena 
described as incident to the alkaline fermentation, taking 
place soon after the urine is passed, if not in the bladder 
itself. 

In diseases of the prostate, are apt to be found long 
plugs of mucus, W'hich, upon microscopic examination, 
will be found made up of aggregated pus-corpuscles, in 
which are sometimes found the larger round or nearly 
round nucleated cells peculiar to this seat. Similar plugs 
are found in the pus from gonorrhoea, and it is said also 
(Neubauer), that in this affection the mucus-corpuscles 
are distinguished from those derived from the bladder by 
their larger size, their " glass-like clearness," and dimin- 
ished granulation. 

In females pus is apt to obtain in the urine from leu- 
corrhoea or other purulent discharge from the vagina. 
This should not be forgotten. 



URINARY DEPOSITS. 143 

2. Epithelium. Epithelium from all parts of the 
genito-urinary tract is found in the urine, but it is not 
very often that we are enabled to locate its site beyond the 
bladder and vagina, partly, because of the comparatively 
slight differences in the epithelium from certain locations, 
and partly, because maceration in the urine renders such 
feeble distinctive points much less so. 

Three varieties of epithelium may, however, be distin- 
guished in urine, with tolerable ease : 1st, round cells ; 
2d, cylindrical or conical and spindle cells; and, 3d, 
squamous cells. 

a. Round epithelial cells (a, Fig. 22) arise from the 
uriniferous tubules, particularly in their convoluted por- 
tion, from the deeper layers of the mucous membrane of 
the pelvis of the kidney, of the bladder, and of the male 
urethra. Some of these cells, originally somewhat flat- 
tened by pressure, swell up in the urine, and become nearly 
round. They are distinguished from pus- and mucus-cor- 
puscles by their larger size and their single nucleus, which 
is distinct without the use of reagents, while the multiple 
nucleus of the pus-cell requires the use of acetic acid to 
exhibit it. There is no way of distinguishing the source 
of these cells more precisely than above, except that i^' 
the urine be albuminous, and there is evidence of renal 
disease, we presume them to come from the tubules <.^^ 
the kidney, or from the pelvis if there are syni[)ioms ot* 
impacted calculus; otherwise from the urethra, the pros- 



144 PKACTICAL EXAMINATION OF THE URINE. 

tate, Cowper's or Littre's glands, but cells from the 
latter are rare. If the plugs already referred to, made 
up of pus-cells with a few larger nearly round and dis- 
tinctly mononucleated cells united by mucus, are present, 
we may infer the round cells to be from the epithelium 

Fig. 22. 




ft, round epithelium from the bladder. 

6, columnar " " ureter and urethra. 

c^, " " deeper layers of epithelium of bladder. 

(^, squamous " " superficial " " *' 



of the prostate. The round cells from the bladder are 
considerably 'larger than those from other sources — twice 
the diameter of a pus-cell. 



UKINAPvY DEPOSITS. 145 

h. Columnar or conical and spindle cells (h, Fig. 22) are 
derived, the first, from the superficial layers of the pelves 
of the kidney, from the ureters and urethra, the latter 
from the ureters and urethra. 

G. The scaly epithelial cells (c, Fig. 22) arise from the 
bladder or the vagina. These are flat, but often thicker 
at the middle, contain a single nucleus, are irregularly 
polygonal in outline, and often turned over on themselves 
either completely or partially. The epithelial cells of 
the bladder (c^) are not generally as large as those of the 
vagina (c^) nor so flat ; they are less apt to occur in layers 
or flakes, although also found thus. Frequently it is 
impossible to distinguish the two. 

In acid urine these cells remain a considerable length 
of time, but in alkaline urine they are gradually 
destroyed, becoming at first swollen and more trans- 
parent. 

3. Blood-corpuscles get into the urine from the tu- 
bules of the kidneys, from the pelvis, the bladder, the pros- 
tate, and from the uterus and vagina in their various phys- 
iological and pathological hemorrhages. They may be 
so abundant as to be easily distinguished in mass by the 
naked eye, or they may require the microscope for their 
detection. Urine containing blood in large amount, is 
impressed with the red color of the latter, but contain- 
ing the moderate amount most frequently oncountoivil in 
urine, it obtains a color dej)ondiuLr on its reaction. It" 



146 PRACTICAL EXAMIXATIOX OF THE URINE. 

the urine is acid, it assumes a peculiar blackish-brown 
color which has long been described as **smoke-hued," 
and which is so characteristic as to enable one who is at 
all experienced, to decide at once as to the presence of 
blood. If, on the other hand, the urine is alkaline in 
reaction, it assumes the bright red color of blood. Urine 
containing blood in any appreciable quantity, is albuminous. 

If blood-corpuscles are present in an amount sufficient 
to produce an appreciable deposit, they form a brownish- 
red pulverulent mass at the bottom of the vial if they 
come from the kidneys or ureters. They are more apt 
to be found in coagula, if they come from the bladder or 
urethra, though this latter is not necessarily the case ; 
for, on the other hand, moulds of clotted blood are some- 
times discharged from the ureters with all the agonies of 
nephritic colic. 

Recognition. Blood-corpuscles are recognized under 
the microscope by the optical properties due to their 
biconcave centres. This is the reversal of light and 
shadoic which they undergo in focussing, the centre and 
periphery alternating in brightness or shadow as the 
object-glass is approximated or removed from the slide. 
This, in connection with their evident biconcavity when 
seen on end, and their yellowish color, will always serve 
to distinguish them, although the eiFects of long continued 
maceration serve to interfere in different degrees with 
the distinctness of all of these features. If the urine is a 



URINARY DEPOSITS. 147 

dilute one, the corpuscles will swell up, become biconvex 
instead of biconcave, finally spherical, and the reversal 
of light and shadow no longer occurs, while the coloring 
matter is more or less dissolved out. Ultimately the 
corpuscle altogether disappears. If, on the other hand, 
the urine is highly concentrated, the concavity becomes 
more marked and more distinctive, while the corpuscle 
itself shrinks and becomes smaller, and soon acquires the 
crenated or horse-chestnut shape (Fig. 23 J. 

Fig. 23. 



w^ 

Blood-disks. 

In an acid urine the blood-corpuscles maintain them- 
selves for a long time, but in an ammoniacal urine they 
are soon dissolved, being soluble in alkalies. The haj- 
matocrystalline and hsematin are then dissolved in the 
urine, and may be tested for as already directed. 

4. Certain Pigmented Markings, commonly 
CALLED "Pigment Flakes" ok ''Pigmentary Par- 
ticles." At this point it may be well to refer, by way 
of precaution, to certain appearances which have boon 
variously designated, but to which the above terms have 
been most frequently applied. 



148 PRACTICAL EXAMINATION OF THE URINE. 

No objects are more constantly met with, and none 
about which explanation is so often asked by the student 
as these, and yet no description of them seems to have 
been published before that of Dr. Roberts in his w ork on 
''Urinary and Renal Diseases." 

Their appearance is that of little pigmented flakes 
which may be roughly compared in outline to squamous 
epithelial cells, such as come from the cutaneous epi- 
derm, and have soaked a little while in water ; yet while 
they are well-defined throughout most of their periphery 
on one side, they generally shade ofi" and become gradu- 
ally invisible. This may be due to the distribution of 
the reddish-brown granules, w^hich are generally more 
closely placed in one part, being so numerous as to make 
the flake opaque or nearly so ; from this they shade off* 
in the manner described, disappearing altogether as the 
edge is approached. At other times the flake is filled 
throughout with pigment, when it appears dark, almost 
opaque, and equally well defined on all sides. The size 
of these "flakes" or "particles" is very various, from 
.008 millimetre to .025 millimetre (-30V0 ^^ ^^^^ Taoo" 
of an inch) ; the majority, and those which usually strike 
the attention, are of the latter size. (See Plate.) 

Strange as it may seem, the appearances are nothing 
more nor less than stained "markings" or "fractures" 
upon the glass. This was only recently pointed out to 
me by my friend Dr. J. G. Richardson, and I have since 




J^ G C£i i^ 2 ^^ U [Fl A3i [ES^ :. 



URINARY DEPOSITS. 149 

amply confirmed the observation. I had myself often 
recognized and demonstrated markings of similar con- 
tour on glass, but these were not pigmented ; and the first 
conclusion to which Dr. R. and myself came was that 
the pigment flakes were the same scratches whicli had 
become filled with the coloring matter of blood or 
other substance which could not be removed by ordinary 
wiping and cleaning ; but a trial with potash on the one 
hand and nitric acid on the other failed equally to remove 
them. What they precisely are, therefore, I do not as 
yet know ; but their real nature thus far determined, 
there now appears abundant reason why it might before 
have been suspected, among w^hich is pre-eminent the con- 
stancy of their occurrence, whatever the object examined. 

5. Tube-casts. Tube-casts are m(fUlds of the urin- 
iferous tubules produced by an admission into the latter, 
by capillary rupture or otherwise, of a coagulable con- 
stituent of the blood, which there solidifies, and in this 
act entangles whatever it may have surrounded in its 
liquid state ; subsequently it contracts and slips out of 
the tubule into the pelvis of the kidney, whence it is car- 
ried to the bladder and voided with the urine. 

The mechanism of the production of the difierent va- 
rieties of casts is very simple. Thus, su})i)ose a tubule to 
be filled with detached and loosely attached ejMtholium 
at the time the fibrin is poured into it. These ilenu nts 
are entangled, and as the cast contracts, carried ont in ihc 



150 PEACTICAL EXAMINATION OF THE URINE. 



shape of an '' epitheliaV' cast (Fig. 24). If the tubule 
should happen to have contained blood, the cast entan- 




Epithelial casts and compound granule-cells. 

gling it is called a ^^ blood-cast^' (Fig. 25). Casts con- 
taining even a few blood-corpuscles are also called blood- 

FiG. 25. 





Blood-casts and highly granular casts. 



casts. If the epithelium be firmly attached to the base- 
ment-membrane of the tube, and remain behind when 



URINARY DEPOSITS. 



lol 



the cast passes out, or if the tube be entirely bereft of 
epithelium, then is the cast a ''hyaline^' (Fig. 26;, or 
structureless cast. In the former instance the cast is of 
smaller diameter, and in the latter of larger ^ the diameter 
in the latter being that of the former plus twice the thick- 
ness of an epithelial cell. Fig. 26 from Rindfleisch ex- 



FiG. 26. 



I 




Hyaline and granular casts illustrating the formation of the former at a. 



plains this sufficiently. A cast is seldom com})letely hya- 
line, generally containing a few granules and one or two 
glistening oil-drops, but it is still called hi/aliiic. Com- 
pletely hyaline casts do, however, occur. A variety of 
hyaline cast, more solid in appearance and re.<omhling 
molten wax, is spoken of as a '' iva.vi/ ca.^t'^ <.Fi.-- -"• H- 
Some hyaline casts are so delicate as to bo overlooked, 



152 PEACTICAL EXAMIXATIOX OF THE UEIXE. 

unless the light from the mirror illuminating the field of 
^^ew be modified by shading with the hand or by manij^- 
ulation of the mirror itself. If a east contains granular 
matter, which is generally the granular debris of a 
degenerated epithelial lining of a tubule or of blood- 

FiG. 27. (After Harley.) 




corpuscles, it is called a ^^ granular ^^ cast, and highly 
granular (Figs. 25 and 26), moderately granular (Fig. 
26, 6), slightly or delicately granular, according to the 
amount of granular matter present. When the material 
of granular casts is derived from broken-down blood- 
corpuscles, the casts appear yellow or yellowish-red. 
Finally, if a cast is loaded with oil-drops, either free or 



UEINARY DEPOSITS. 



1 o3 



contained in epithelial cells, it is called an "o/7-r;a.s//' 
or fatty cast (Fig. 28). 

Casts of smaller diameter are sometimes found within 
those of larger, the material of the latter having been 
poured out around that of the former after it has 
undergone some contraction. This occurs usually with 
waxy or hyaline casts. In consequence of the mode 

Fig. 28. 






I 




Oil-casts and fatty epithelium. 



of formation above referred to, hyaline and waxy casts 
vary considerably in diameter, some being as narrow as 
the .025 millimetre (j^/^^jth of an inch) and even nar- 
rower, while others are as much as .Or> milliniotre (-s-J-o^l^ 
of an inch) wide. There is no doubt but thai some 
of these are formed in the straight or collecting tubes 



154 PBACTICAL EXAMIXATIOX OF THE URINE. 

near their openings on the papilla. To these a limited 
number of epithelial cells is sometimes attached. 

In addition to the epithelial casts above described, 
there are found in urine under the same circumstances 
moulds of the uriniferous tubules made up of simple 
aggregations of the epithelial cells themselves — simple 
exfoliations of the cellular contents of the tubule, which 
having increased by proliferation form a compact cellular 
mass, which may be called " epithelial cylinders." In 
addition to thes^ also are sometimes found epithelial 
casts in which the cells are seated on the outside or 
around the fibrinous mould. 

Mucus- Casts. Casts are occasionally found, which are 
apparently pure mucics-moitlds of the uriniferous tubules. 
Unless covered by accidental elements, as granular urates 
or phosphate of lime, they are smooth, hyaline or gently 
fibrillated moulds, especially characterized by their great 
length, which is often enormous, in the course of which 
they divide and subdivide reducing in diameter as the 
division proceeds, showing positively that they come 
from the kidney. Yet there is no albumen or merely as 
much as could be accounted for by the. presence of pus 
which sometimes attends them. For they are particu- 
larly apt to occur where there is irritation of the bladder, 
which is apparently extended through the ureters to the 
kidney. Under these circumstances, I have met them on 
two or three occasions. Dr. Beale says (Kidney Diseases, 



( 



URINARY DEPOSITS. 155 

etc., p. 342), they are not unfrequently passed in cases 
where the urine has a very high specific gravity, 1030 or 
higher, containing an excess of urea and urates. 

These casts are not identical with the bands of mucin 
already alluded to, p. 136, which are found in the urine 
of highly acid reaction, perhaps precipitated by the acids, 
which are often beset with granular urates, and might be 
mistaken for casts. 

Casts of the seminal tubules are sometimes found in the 
urine, but their origin may be inferred from the presence 
of spermatozoids in them. 

To Prepare Urine for Examination for Casts. The 
greatest caution should be exercised in examining urine 
for casts. They are often so sparsely present as to fur- 
nish no deposit appreciable to the naked eye, and yet 
may be found by careful microscopical examination. 
While it is not impossible for non-albuminous urine to 
contain casts, yet I have never met them, except perhaps 
in a single instance, where albumen and casts having 
been present, in their gradual disappearance the signs 
of the presence of albumen disappeared before the hist 
casts had been washed out. On the other hand the 
presence of albumen means casts in the vast majority of 
instances, and many times I am certain they are declared 
absent, simply because they are not carefully sought. 
Not a single slide should satisfy the exam I nor, but two 
or three should be carefully studied throughout their 



156 PRACTICAL EXAMINATION OF THE URINE. 

entire field. Nor is a plain slide sufficient. Urine should 
be examined in shallow cells, and as those of thin glass 
are generally too deep, the best are made with gum- 
dammar or Bell's cement, by means of a turntable and 
brush, since in this way they may be obtained sufficiently 
shallow to allow them to be penetrated by an ordinary 
one-fifth or one-fourth objective. After being made they 
should be put away for a month or more to thoroughly 
dry and harden, else they are washed ofiT with the first 
cleaning of the slide. 

Most casts from their lightness subside slowly, and the 
more so because the urine is albuminous. As soon as 
received, therefore, the bottle of urine should be shaken 
up, poured into a conical glass, and carefully covered. 
Although casts generally fall to the bottom in a shorter 
time, I have known twelve hours to elapse before one could 
be discovered, and therefore whenever it is possible, urine 
should be allowed to stand for this time in a conical glass, 
and examined the next morning. If the urine has already 
been standing some time, the supernatant fluid may be 
removed, and only the lower strata containing the sedi- 
ment turned into the conical glass, and allowed further 
to subside. A pipette, consisting of a plain glass-tube 
drawn nearly to a point, should then be carried to the 
bottom of the glass with the index finger firmly pressed 
upon the distal end. When it has reached the bottom, 
the finger should be raised for a second only, and quickly 



TTRINAIIY IJ P:P08ITS. 157 

returned. In this manner only the lowest drops are 
obtained, which are mostly likely to contain the casts. 
A drop of this fluid is allowed to fall into one of the 
shallow cells, covered with a thin glass cover, and care- 
fully examined with a one-fourth or one-fifth object-glass 
and the A eye-piece. If these precautions are taken, 
and two or three slides examined, casts will either be 
found, or they are absent. Only the beginner need be 
cautioned against linen and cotton fibre, hair, or portions 
of deal-wood. More likely are the mucin flakes and cast- 
like granular aggregations of inorganic and organic mat- 
ter to mislead. 

6. Spermatozoids frequently occur in the sediment of 
urine of healthy individuals. When abundant, they form 
a slight flocculeut cloud in the urine, but there is generally 
nothing in the appearance of urine whence their pres- 
ence may be suspected. They require a power of 400 dia- 
meters (one-fifth with the B eye-piece) to show them well, 
when they may be recognized by the oval head or body 
and the delicate tail-like prolongation emanating from 
it. They no longer exhibit their vibratile movement 
after entering the urine. Their recognition is most inter- 
esting in connection w^ith medico-legal cases — cases of 
suspected rape. Their presence in vaginal mucus soon 
after coition and in stains upon linen, is easy of demon- 
stration. In the former ease a drop of mucus from within 
the vagina is placed upon a. slide, a drop oi' water added 

14 



158 PRACTICAL EXAMINATION OF THE URINE. 

if necessary, covered with a thin cover and examined with 
the microscope. In the latter a simple piece of the stained 

Fig. 29. 




Human spermatozoids. 1. Magnified 350 diameters. 2. 800 diameters, 
rt, viewed from the side. 6, from the front. 

linen may be soaked in water or artificial serum in a 
watch-glass for half an hour or an hour, and the sediment 
examined. Beale figures (Fig. 74) some filaments of a 
vegetable nature resembling spermatozoids. 

7. Fungi. Most of the living organisms found in de- 
composing urine, formerly looked upon as of animal 
origin, are now acknowledged to be vegetable in their 
nature, and are generally called fungi. 

The most frequent among these are bacteria, penici- 
lium glaucum, and the yeast fungus. Sarcin?e are occa- 
sionally met with. 



URINARY DEPOSITS. 159 

1. Bacteria, In the refined study which has of late 
years been given to the subject of fungi, a classification 
has been made of the minute objects which were formerly 
called bacteria or vibriones. I take from Hoffmann and 
Ultzmann the classification of A. Vogel, who makes of 
them, a, the monad form, consisting of little trembling 
points distinguished in their molecular movement from 
'that of inorganic particles, by a progressive motion ; b, the 
staff-shaped bacteria, which appear as minute lines equal- 
ling in length with moderate powers the diameter of a red 
blood-disk, but mere lines in breadth, sometimes at rest, 
and sometimes vibrating across the field ; c, the vibrio 
form, consisting of two or more of the staff-shaped bacteria, 
adherent end to end, and moving often with great rapid- 
ity, sometimes by a spiral movement, and sometimes by 
vibrating one extremity, as a fish propels itself; d, the 
leptothrix form, or chain fungus, often extending entirely 
across the field of view, differing from the vibrio forms 
only by their length, moving seldom, and if at all very 
slowly ; e, the zooglea form, consisting of heaps of bacteria, 
mostly punctiform, apparently held together by a gelati- 
nous substance. 

2. The yeast or sugar fungus, identical with the ordi- 
nary yeast fungus, consists in the sporule-stage of trans- 
parent oval cells, in their longer diameter about the 
size of a blood-disk, and of hirger spherical colls, Liranu- 
lar and nucleated, lound in saccliariue urine, i Fiu". '^0.^ 



160 PRACTICAL EXAMIXATIOX OF THE URTXE. 

According to Hassall, this is a fungus peculiar to saccha-. 
rine urine, but the small oval cells of the sporule-stage at 
least cannot be distinguished from the similar stage of 

Fig. 30. (After Harley.) 




3. Penidlium glaucum, which occurs in acid urine 
with or without albumen or sugar. The sporule-stage fur- 
nishes cells very similar to those of the yeast fungus, but 
later, penicilium by the union of its cells forms thalli or 
branches which are characteristic. So, too, in the stage 
of aerial fructification, the penicilium multiplies by 
simple linear division of cells, while the spores of the 
sugar fungus fall from a spherical mass not unlike that on 
the stem of an onion ^^ going to seed." 

4. The sarcina is a fungus rarely met with in urine. 
Composed of cubes, it is capable of further separation into 
smaller cubes. It is similar to, but smaller than the 
sarcina ventriculi of Goodsir. 

The germs of these fungi doubtless enter the urine 
after it has passed from the bladder, in the vast majority 
of instances, one or the other form being developed 



URINARY DEPOSITS. 161 

according to the properties the urine may possess. De- 
composition seems essential to the presence of the bacteria, 
but not to the other forms. 

8. The elements of morbid growths are seldom 
met in the urine. Possibly cells may be found, and pos- 
sibly fragments of the growth may be broken off and 
passed with the urine. The former may be suspected to 
be of morbid origin by their large size, their multi- 
nuclear character, the large size of the nuclei, and di- 
versity of the cell-forms. Spindle-cells, it must be re- 
membered, may be derived from the ureter, urethra, and 
even the bladder, and must not of themselves, therefore, 
be considered as indicating cancer. 

Fragments of cancerous grow^ths \vhich get into the 
urine are generally from the villous kind, and may show^ 
the capillary vessels which make up the. villus, with or 
without the epithelial covering. Fragments, suitable for 
examination, are sometimes withdrawn with the catheter. 

9. Entozoa are seldom found in the urine in this cli- 
mate. Echinococcus cysts, as well as their booklets, have 
been passed in two or three instances recorded. The eggs 
and ciliated embryos of Bilharzia hcematobia have been 
found by Dr. John Harley in three patients with the en- 
demic hcematuria of the Cape of Good Hope, and I had the 
privilege, through the kindness of my friend. Dr. S. W. 
Gross, of examining one of the slides containing ova, sent 
to this country. The parasite itself is finind in the vosi- 



1()2 rUAOTJOAL EXAMINATION OF V\U] IKl NK. 

ci\\, inosontori(\ and portal voins, eausino- honiorrha^os 
into the intostinos, bhuhlor, iirolors, and pelvis ot'tiio kid- 
noy. Tho ova anil parasite are iiii'urod by Bealo, op., }). 
402. 

Dii^fo})i'i h(r)))afohtu))i has been iound in the bladdiM', 
ureters, and pelvis of the kitlney, especially in l\iivj>t. 



OfAGXOSIS OF \:i:SA\. IMSKASKS. 1 0'> 



DIFFERENTIAL DIAGNOSIS OF RP:NAL DISEASES. 

While it is fjuite impossible to determine with aVjsolute 
certainty all of the different affections to which the kid- 
neys are liable, by a mere examination of the urine, there 
is nevertheless an association more or less close of signs 
with well-determined conditions. With such association 
it is important that we should be familiar, while we 
should as well recognize the fact that they are subject to 
variations and exceptions. If these truths are properly 
remembered, it is not likely that any one can be led far 
astray by observing the following: 

I. The urine is scanty, dark, '*' smoke-hued," so long 
as it remains acid, but becomes red if alkalized. It is 
highly albuminous. Its specific gravity is not constant, 
but apt to be high — 1025 or above — not from an increase 
in urea, but from the presence of blood. It contains a 
variable, but generally large amount of reddish-brown, 
pulverulent sediment, which, on microscopic examina- 
tion, is found made up of large epithelial casts and epi- 
thelial cylinders, blood-casts, hyaline casts of large dian]- 
eter, dark-red granular casts, numerous red blood-disks, 
and free cells, more or less round and nucleated, twice 
as wide as the blood-disks, cloudv, and more iii-anular 



164 PRACTICAL EXAMINATION OF THE URINE. 

than in health, the granules often obscuring the nucleus. 
Crystals of uric acid are often present. The chlorides 
are at first diminished, also the earthy phosphates. 
Hsematin, indican, and uric acid are increased. 

The patient is dropsical, much swollen about the face, 
and, if a child, has had scarlet fever, or, if an adult, has 
been exposed to wet while perspiring. 

The disease is acute nephritis, scarlatinal nephritis, or 
acute Bright's disease, and the chances for recovery are 
many. 

II. The urine is pale, and of low specific gravity — 
1005-15 ; its quantity, though variable, generally dimin- 
ished. Albumen is diminished as compared with (I), 
but is still abundant — one-quarter to one-half the bulk. 
It deposits an appreciable white sediment, which, by mi- 
croscopic examination, is found made up of black, highly 
granular casts, hyaline casts, and casts containing frag- 
ments of epithelium ; also compound granule-cells (Fig. 
24). Probably also there are casts containing a moderate 
quantity of oil, and perhaps also partially fatty cells. 
The urea is diminished, the chlorides normal, pigment 
diminished. There is also oedema, more or less general, 
which may, however, subside, but the patient has a pale, 
almost characteristic waxy look. The symptoms have 
existed more than six weeks. 

The disease is probably the large white kidney, a 
chronic continuation of (I), known also as chronic tubal 



DIAGNOSIS OF RENAL DISI:ASES. 165 

I nephritis, and recovery, though pos.sihle, is not likr^ly to 
occur. 

III. The urine presents the same general characters as 
in the last case, contains rather niiore albumen, and a 
more abundant sediment, which is found made up of nu- 
merous oil-casts filled with free oil, and oil contained in 
epithelial cells. There are numerous free fatty cells, and 
free oil-globules. The urea is diminished. 

It is the true yellow fatty kidney, which, sometimes at 
least, originates independently of any acute inflamma- 
tion of the organ, in drunkards. Dropsy is persistent. 
The disease is pre-eminently fatal. The patient exhibiting 
; the peculiar cachexia mentioned under (II), will gener- 
ally perish within the year. 

IV. The disease has existed for more than a year, the 
urine varies in amount, but is at least not so much dimin- 
ished, and the specific gravity is somewhat higher than 
in (II). The albumen is diminished, but is still consid- 
erable. The urine deposits a more scanty sediment, made 
up of hyaline casts, some of which contain fragments of 
epithelial cells, some are partially filled with oil-drops, 
while some are still highly granular. Compound granule- 
cells occur, but are less numerous, and there may be some 
fatty epithelial cells, but the amount of oil, though dis- 
tinctive, is not very large. The urea is much dimin- 
ished. There is generally some dropsy, loss than in 1 . 
(II), and (III), but more than in (V). 



166 PRACTICAL EXAMINATION OF THE URINE. 

Here the large white kidney has probably coimnenced 
to contract, but one must be cautious about drawing too 
sharp a line between these two affections. The prognosis 
is unfavorable, but the disease may last some time — even 
years. 

V. The urine is increased in amount, correspondingly 
pale, but, while micturition may be a little more fre- 
quent, it may not attract attention. The patient may 
have to rise once in the night. The specific gravity is 
little, if at all, diminished — 1018-20 — while the quantity 
of albumen is trifling, never exceeds one-quarter, and 
often is shown by a mere line of opacity in Heller's test. 
It deposits often no visible sediment, and at all times a 
trifling one. In this are found delicate hyaline, and 
finely granular casts, often of small diameter. Some of 
these contain one or two glistening oil-drops, but very 
minute. Here are found the casts which are at times 
almost invisible. The urea is generally slightly dimin- 
ished. 

There is no dropsy. There are often no symptoms 
whatever connected with the disease. If any, the pa- 
tient may complain of a weak, tired feeling, and this 
symptom should suggest an examination of the urine 
always. The disease may exist for years without the 
knowledge of the patient, who may or may not be sub- 
ject to gout. (The urine of gouty patients should be fre- 
quently examined.) 



DIAGNOSIS OF ItKN^Af. DISEASES. 107 

The disease is the chroiiimlly contraded kidney, the 
interstitial nephritis of the German pathologists. If expo- 
sure to cold and fatigue be avoided, the patient's life 
niaybe scarcely shortened, and yet he is constantly liable 
to attacks of unx3mia, which may suddenly terminate his 
life. 

VI. The urine is normal in quantity or increased, clear, 
of low specific gravity, 1015, of a pale, golden color, the 
color of a dilute urine only, contains considerable albumen, 
about one-fourth ; urea is diminished. There is very little 
or no sediment visible. Casts are often wanting, and 
when present are hyaline and waxy, the latter solid-look- 
ing, sometimes giving the characteristic red reaction of 
the albuminoid substance when treated with a wafer i/ so- 
lution of iodine and iodide of potassium. Here hyaline 
casts of large diameter are found, and sometimes within 
these smaller casts. 

There is apt to be dropsy, sometimes persistent, but 
generally, except towards the termination of the case, 
amenable to treatment by rest and diuretics. The pa- 
tient has an enlarged liver or spleen, sometimes per- 
sistent diarrhoea ; he has had syphilis, or extensive dis- 
ease of the bones, or has phthisis. 

Tlie disease is albuminoid de(jc)ierafio)t of the kidnrji, 
and is incurable, though the patient may live many 
years. 

The above is ^X'^yq.w as a general guide, and 1 would 



168 PRACTICAL EXAMIXATIOX OF THE UKIXE. 

again refer to the fact that there are deviations from the 
conditions laid down. There are still many points quite 
disputed in the pathology of the kidney. Thus, the 
German pathologists contend that there is a constant 
relation of succession between the acute j^arenchymatous 
nephritis, the chronic parenchymatous nephritis (large 
white kidney), and the contracting stage of the latter, 
making no distinction between the large white kidney 
and the fatty kidney. Both, it is true, are fatty kidneys, 
but while the fi\t in the former is molecular or granular 
fat, in the latter it is globular. Although these two may 
also at times be different stages, the latter being the more 
advanced, no fact is better determined than that the true 
fatty kidney may originate insidiously without any acute 
attack. ^ 

One more fact must be mentioned in this connection, 
and this is that although the presence of fatty casts and 
fatty epithelium are unfavorable symptoms, yet it does 
not follow that such cases are necessarily fatal. I have, 
on more than one occasion, found oil-casts in the urine 
of patients, and yet have also found them to disappear 
altogether. The circumstances under which this has oc- 
curred have been, 1st, where there has been heart dis- 
ease and kidney disease combined, and there has been 
some exacerbation of one or both, when the albumen 
has increased, and oil-casts have made their appearance. 



1>1AGN(>SI.S OF IJEXAI. DISEASES. lOli 

which later, totally di.sappear(3(l ; 2(1, where pregnancy 
has supervened on existing Bright's disease, and oil-casts 
have been present, which again disappeared after a suc- 
cessful labor. 



170 PRACTICAL EXAMINATION OF THE URINE. 



TO DETERMINE THE COMPOSITION OF URINARY 
CALCULI f 

The qualitative analysis of gravel or calculi is much 
simpler than is generally supposed. There are but three 
forms of calculi, which are of at all common occurrence, 
" and which are, therefore, likely to demand analysis. 
These are uric acid, oxalate of lime, and the mixed j)hos. 
phates. 

1. Uric acid calculi are the most common. They are 
either red or some shade of red, and usually smooth, but 
may be tuberculated. They leave a mere trace of resi- 
due after ignition. 

Test Their nature may be determined by reducing a 
fragment to powder, and applying the murexid test as 
described, p. 86. 

2. Oxalate of lime calculi are frequently met with. 
They are generally of a dark-brown or dark-gray color, 
and from their frequently tuberculated surface have been 
called mulberry calculi. They may, however, also be 
smooth. Considerable residue remains after ignition. 
The calculus is soluble in mineral acids without efferves- 
cence. 

To test a calculus suspected to be oxalate of lime, ig- 
nite some of the powder on platinum-foil, at a red heat, 
bv which it is reduced to carbonate of lime. If a small 



RECORDING AN EXAMINATION. 171 

quantity of the i-esulting powder be placed on a ^la.ss 
slide, covered with a thin cover, and treated with acetic 
acid, effervescence will be ^observed with or w^ithout the 
microscope. Or a portion of the original powder may 
be heated in the blowpipe flame, by which it is reduced 
to caustic lime, which promptly hluen reddened litmus- 
paper. 

3. Calculi of the Mixed Phosphate or Fusible Calculi 
are composed of the phosphate of lime and of the triple 
phosphate of ammonia and magnesia. They form the 
external layer of many calculi of different composition, 
and may form entire calculi, but very seldom form the 
nuclei of other calculi. They are exceedingly brittle, 
soluble in acids, but insoluble in alkalies. 

Test. They may be known by the above properties, 
and by fusing in the blowpipe flame into a hard enamel. 

Few calculi of large size are of the same composition 
throughout. Oxalate of lime is the most frequent nu- 
cleus, but uric acid may also serve as a nucleus, Init 
phosphates, as stated, almost never. Small collections 
of organic matter, as blood-clots, frecpiently lonn nuclei, 
and may often be recognized by the odor of amnion in 
on ignition. It is not uncommon to iind calculi made 
up of concentric layers of different composition. 

MODIO OF Ki:('()KI)IX(; AN KX A M I X A lU^N. 

To systematize and I'acilitati^ the work ol" nrine exami- 
nations, forms of record have been devised hv tlioM^ 



172 PRACTICAL EXAMIVATIOX OF THE rRESE. 

working in the subject. I have for some time used, with 
great convenience, that suggested by Prof. Austin Flint. 
Jr., in his manual on the Chemical Examination o: 
Urine, but for ordinary use in hospital and private 
practice that of Heller recommends itself for its economy 
and readiness. 

Heller recommends that an ordinary half-sheet of 
letter paper be folded in four, and marked as indicated 
below: 



Physic Ai -j. izz 
j Quantilhr in nreniy-four hours. 



j! Cc^r and reacuon. 



li Sp. ?r.. 



QaantJty of sediment. 



Uph. ulTropliam.) 
Ux. iTJioiLantliin.) 

e.arrea.) 

U. -^TTric acid- « 



CL (Chlorides.) 

Ejih. (Eaxthv phoiq»hates.) j 

Alkaline pho^rfiates. || 

Solphaii^. 

L"03fSIiIlEXT> ZS SOLrXI-'V. 



SEDDoyr. 



RE(X)IU)IN(; AN KXAMINATIOX. 



iVy 



Abbreviations for the important constituents are used 
as shown, and the sign ^' + '' for increaHcd, the sign *' — " 
for diminished J and the letter " n " i'ov norinaL For (jreat 
increase or r/rea^ diminution, "gr. + " and " gr. — '' may 
be used, and for slight increase or diyJd diminution, 
'' si. + " or " si. — ." 

Let us suppose an examination to have been made, 
with the following results. The word ^' indican," ^' ind.'" 
is preferred for " uroxanthin," and substituted. 



I 



Physical Properties. 




Quantity in twenty-four hours, 500 c. c. 




Color, very pale yellow. Reaction, acid. 




Sp. gr., 1005. Sediment, moderate. 




Normal Constituents. 




Uph. gr. — Cl. 11. 




Ind. si. H- Eph. — 




u ] .,._ ^i>^^-| _ 




U J Sph. J 




Abnormal Constituents in Solution. 




Albumen, 50 per cent. 




Sediment. 




Numerous oil-easts, free fatty cells, and frrt> ^ 


>il- 


glol)Ul(>S. 




Diagnosis — Fat t y kid uey . 





l.-> 



174 PRACTICAL EXAMINATION OF THE URINE. 

TABLES 

For Beducing the Metric or French System into the English^ 
and vice versa^ as far as required in Urinary Analysis. 

(Jrammes to Grains. Grains to Milligrammes. 

1 = 15.43 ( -1- .0022) 1 =:=. 64.8 (— .000425) 



2 


= 30.80 


3 


= 4629 


4 


= 61.72 


5 


= 77.15 


6 


= 92.58 


7 


= 108.01 


8 


= 123.44 


9 


= 138.87 



2 


= 129.6 


3 


=- 194.4 


4 


= 259.2 


5 


-= 324.0 


6 


-= 388 8 


7 


=. 453.6 


8 


= 518.4 


9 


= 583.2 



Cubic Centimetres to Minims. Minims to Cubic Centimetres. 

1 = 16.2 ( + .0293) 1 = .0616 



2 = 


32.4 




2 


= 


.1232 


3 = 


48.6 




3 


= 


.1848 


4 = 


64.8 




4 


= 


.2464 


5 = 


81.0 




5 


= 


.3080 


6 = 


97.2 




6 


= 


.3696 


7 = 


113.4 




7 


= 


.4312 


8 =^ 


129.6 




8 


= 


.4928 


9 =-* 


145.8 




9 


=^ 


.5544 


Cubic Centimetres to Fluid 
Drachms. 


Fluid Drachms to Cubic 
Centimetres. 


1 = 


.27 ( + 


.0005) 


1 


= 


3.7 


2 = 


.54 




2 


= 


7.4 


3 = 


.81 




3 


= 


11.1 


4 = 


1.08 




4 


= 


14.8 


5 = 


1.35 




5 


= 


18.5 


6 = 


1.62 




6 


= 


22.2 


7 = 


1.89 




7 


= 


25.9 


8 — 


2.16 




8 


.^_^ 


29.6 


9 -- 


2.43 




9 


^ 


33.3 







tabIvP:s. 






'es to Fli 


lid Oimcos. 


Flni 


d Ounces 


to Cubic rcrjtirnctrf 


1 = 


33.8 ( i 


.011) 


1 


= 


30 (_.4238j 


2 = 


G7.6 




2 


= 


60 


8 = 


101.4 




3 


= 


90 


4 = 


135.2 




4 


= 


120 


5 = 


169.0 




6 


= 


150 


6 = 


202,8 




6 


= 


180 


7 = 


• 236.6 




7 


= 


210 


8 = 


270.4 




8 


= 


240 


9 ^ 


304.2 




9 


= 


270 


Litres to Pints. 




Pints 1 


to Litres. 


1 = 


2 1 ( -r 


.013188; 


1 


= 


.473 ( -r .0002 


2 == 


4.2 




2 


= 


.946 


3 = 


6.3 




3 


= 


1.419 


4 = 


8.4 




4 


= 


1.892 


5 = 


10 5 




5 


= 


2 365 


6 = 


12.6 




6 


= 


2.838 


7 = 


14.7 




7 


z= 


3.311 


8 = 


16.8 




8 


= 


3.784 


9 = 


18.9 




9 


= 


4.257 



17.5 



Inches to Millimetres. Millimetres to Inches. 

.00005) 



1 


= 


25.4 ( 


2 


= 


50.8 


3 


= 


76.2 


4 


= 


101.6 


5 


= 


127.0 


6 


= 


152.4 


7 


z= 


177.8 


8 


z= 


193.2 


9 


=. 


228.6 



1 


= 


.08937 


2 


= 


.07874 


3 


= 


.11811 


4 


= 


.15748 


5 


= 


.19685 


6 


= 


.23622 


7 


= 


.27559 


8 


= 


.31496 


9 


= 


.35433 



17(5 



PIIACTICAT. 


Metres i 


o Feet. 


1 = 


3 28 


9 _, 


6.56 


3 = 


9.84 


4 = 


13.12 


5 = 


16. JO 


6 = 


19.68 


7 = 


22 96 


8 = 


26.24 


9 = 


29.52 



EXAMINATION OF THE URINE. 



Feet to 


Metres. 




1 = 


.3048(': 


- .0000005 


2 = 


.6096 




3 = 


.9144 




4 = 


1.2192 




5 = 


1.5240 




6 = 


1.8288 




7 =^ 


2.1336 




8 = 


2.4384 




9 = 


2 7432 





To Convert Degrees of FahrenheiVs Therr)iometer to 
Centigrade^ and vice versa. 

Centigrade to Fiihrenheit. Fahrenheit to Centigrade. 



1 


= 


1.8 


2 


= 


3.6 


3 


= 


54 


4 


= 


7.^2 


5 


= 


9.0 


6 


= 


10.8 


7 


= 


12.6 


8 


= 


14 4 


9 


= 


16 2 



1 


= 


.555 ( - 


^ .000555) 


2 


= 


1.110 




3 


= 


1.665 




4 


r= 


2.220 




5 


= 


2.775 




6 


= 


3.330 




7 


= 


3.885 




8 


= 


4 440 




9 


= 


4.995 





To use this table, convert the given 
number of degrees Centigrade into 
degrees Fahrenheit, and add 32°. 



To use this table, subtract 32° from 
the given number of degrees Fah- 
renheit, and convert the remainder 
into degrees Centigrade. 



[From Dr. Craig's Decimal System.) 



ADDENDA. J 7' 



ADDENDA. 



NOTE TO PAGE 41. 

TiiJO carbolic acid test in tho alcoliolic and acetic acid mixture 
reconnmended by Mehu, has not been satisfactory in my hands, 
the milkiness which occurs when carbolic acid is mixed with 
water or non-albuminous urine obscuring the results. With 
the mixture of equal parts of acetic and carbolic acids, recom- 
mended in a recent number (September 26, 1874) of the London 
Medical Times and Gazette, 1 have not yet had sufficient experi- 
ence. 

It might also be said with regard to the method there described 
of applying Heller's test, of first placing a suitable quantity of 
nitric acid into a test-tube, and then allowing the urine to fall 
gently upon it so as to '' overla}^ '^ it, — that I have habitually used 
it as well as the method described in the text, which is more pre- 
cisely Heller's, and have found no practical difference in results. 

NOTE ON A CONVENIENT METHOD OF TRANSPORTING URINE, 
ESPECIALLY IN WARM AVEATHER, FOR A DISTANCE. 

While returning the last "revise" to the printer, the follow- 
ing note was received from my friend Dr. W. W. Keen, whose 
experiments with chloral as a preservative are already well 
known to the profession : 

*' I have been testing the preservative properties of chloral, 
and also its possible erroneous conclusions. I find it will preserve 
urine for some weeks even, and give the chemical tests for albu- 
men and sugar, and preserve for microscopical examination 
spermatozoids, epithelium (tube-casts 1 have yet not tried), 
phosphates, and uric acid, etc. Apj^arently it may prove oi^ great 
value tluMH^fore for the examination oi" the urine at a distance, 
whethei' in time or phuc." 



INDEX. 



Acid fermentation of urine, 24, 107 

Acute nephritivS, 16:^ 

Albumen, to detect, by heat, 3C) 

by nitric acid, 37 

by picric acid, 41 

by cnrbolic acid, 177 
quantitative estitnation of, 41 
Alkaline fermentation of urine, 25, 109 
Alkapton, 45 
Apparatus required for urine examination, 16 

Bacteria, 159 

Biliary acids, Pettenkofer's test for, 72 

coloring matters, Heller's test for, 70 

decomposed, test for, 72 
Gmelin's nitrous acid test for, 69 

Blood, coloring matters of, in urine, 63 

Blood-corpuscles in the urine, 145 

Calculi, urinary, to determine composition of, 170 

Carbonate of lime, deposits of, 131 

Chlorides, Mohr's nitrate of silver volumetric process for, 94 

clinical significance of, 92 

nitrate of silver test for, 91 

Liebig's volumetric process for, 92 

detection and approximate estimation of, 91 
Coloring matters, abnormal, 03 
Creatin, 89 
Creatinin, 89 

Cystin, chemical characters of, 133 
deposits, 132 

Dumb-bells of oxalate of lime, 1 22 

Entozoa, 161 
Epithelium, 143 

Fungi, 158 



180 INDEX. 

Gonorrhoea, pus from. 142 

Haematin. Hellers test for, 64 
HaemiD erjstais. to prepare, 64 
Hipparic acid. 90 

IndicaD. elinieal signifieinee of, in arice, 62 
Heller's test for, 59 



Kidney, large white, 164 

fattv coDtracting, 165 
albaminoid, 167 
chronic.tliv eoritraeted. 166 
true jellow fatty, 165 

leacin as a nrinary deposit, 132 
detection of^ 75, 132 

Morbid growths, elements of, in arine, 161 
Macus. 135 
Mocos-casts, 154 
Macus-corpascles, 137 

Nephritis, aeate, 163 

chronic tubal, 164 



Octahedra of oxalate of lime. 122 
Oxalate of lime, deposits of, 121 

elinical significance ot, 126 

form-ition of. 125 

recognition ol 122 

chemiesil charaeters of. 123 

Peniciliom glaaeooi, 150 
Phosphate of lime, deposits of, 12S 

their recognition, 130 
Phosphates, alkaline, approximate estimition of, 99 
ammonio-magnesian, deposits of. 127 
earthy, detection and approximate estimation, 9> 

clinical significance of, 93 
alkaline, clinical significance of, 100 
Phosphoric acid, volumetric process for, 100 
Pigment flakes. 147 
Pus-corpascle. 137 

action of reagents. 138 
Pus. characters of arine containing. 139 
Donne's test for. 140 
sources of, in the urine, 142 



INDEX. 181 



Reagents required for urine examination, 15 

Recording an exjunination, 171 

Renal diseases, differential diagnosis of, 1G3 

Sarcinn, 160 

Selecting a specimen of urine, 18 

Seminal tubules, casts of, 155 

Spermatozoids, 157 

Sugar, fermentation test for, 50 

approximate estimation by Moore's test, 52 

by Roberts's fermentation test, 52 

volumetric process for estimating, 53 

to detect the presence of, by sp. gr. and quantity, 43 

Moore's and Heller's test for, 44 

Tromraer's test for, 45 

Fehling s solution for testing and estimating, 47, 48 

Pavy's solution for testing and estimating, 49 

Boetger's bismuth test for, 50 
Sugar fungus, 159 
Sulphates, clinical significance of, 103 

detection and approximate estimation, 102 
Sulphuric acid, volumetric process for, 103 

Tables, 174 
Tube-casts, 149 

Tyrosin as a urinary deposit, 132 
detection of, 75, 132 

Urates, 88 

deposits of, 117 

their test and recognition, 120, 121 
Urea, volumetric analysis for, 80 

detection and estimation of, 76 
Uric acid, 86 

deposits of, 113 

deposits, recognition of, 114 

tests for, 116 
detection by microscope, 86 
murexid test for, 86 
carbonate of silver test for, 87 
quantitative estimation of, 87 
Urinary deposits, classification of, 112 

rationale of production of certain forms. 10»i 
to preserve during transit in warm weather, 177 
unorganized, 113 
Urine, to prepare, for examination for casts, 155 
odor of, 31 

to determine solid matters of, 32 
order of examination of, 34 
coloring matters of, 56 

16 



182 INDEX. 



Urine, secretion of, 13 

acid fermentation of, 24, 107 

general, physical, and chemical characters of, 19 

its transparency and deviations therefrom, 19 

consistence of, and deviations therefrom, 22 

color of, and deviations therefrom, 22 

reaction of, 24 

specific gravity of, 25 

to determine specific gravity of, 27 

quantity of, and variations, 29 
Urinometer, Heller's, 28 
Uroerythrin in urine, 66 

detection of, 67 
clinical significance of, 67 
Uroglaucin, or indigo blue, 60 
Urohfematin, Harley's test for, 58 

or urophain reaction, chemical significance of increased, 
61 
Urophain, Heller's test for, 57 
Uroxanthin. Heller's test for, 59 
Urrhodin, or indigo red, 60 

Vegetable coloring matters in urine, 68 

detection of, 68 

Xanthin, 89 



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Publications, 

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